Optical Coherence Tomography (OCT) Guided Coronary Stent Implantation Compared With Angiography: A Multicenter Randomized Trial in PCI - ILUMIEN IV: OPTIMAL PCI

Contribution To Literature:

The ILUMIEN IV: OPTIMAL PCI trial failed to show that OCT-guided PCI improves clinical outcomes.


The goal of the trial was to evaluate optical coherence tomography (OCT)-guided revascularization compared with angiography-guided revascularization among patients undergoing percutaneous coronary intervention (PCI).

Study Design

  • Randomized
  • Parallel
  • Prospective

Patients undergoing PCI were randomized to OCT-guided revascularization (n = 1,233) vs. angiography-guided revascularization (n = 1,254).

  • Total number of enrollees: 2,487
  • Duration of follow-up: median 2 years
  • Mean patient age: 66 years
  • Percentage female: 23%
  • Percentage with diabetes: 41%

Inclusion criteria:

  • ≥18 years of age
  • Undergoing PCI
  • Evidence of myocardial ischemia
  • At high risk or had high-risk coronary artery lesions
  • High-risk characteristic defined as diabetes on medication, and/or non–ST-segment elevation myocardial infarction (NSTEMI) or STEMI, long or multiple lesions (planned total stent length ≥28 mm), bifurcation lesion, severe calcification, chronic total occlusion, in-stent restenosis

Exclusion criteria:

  • STEMI ≤24 hours from onset of ischemic symptoms
  • Creatinine clearance ≤30 ml/min/1.73 m2
  • Hypotension, shock, or need for mechanical support or intravenous vasopressors
  • Heart failure (Killip class ≥2 or New York Heart Association class ≥3)
  • Left ventricular ejection fraction ≤30% by the most recent imaging test within 30 days prior to procedure
  • Unstable ventricular arrhythmias

Principal Findings:

The primary imaging endpoint, acute minimal stent area, was 5.72 mm2 in the OCT group vs. in 5.36 mm2 the angiography group (p < 0.001).

The primary clinical endpoint, target vessel failure at 2 years, was: 7.4% in the OCT group vs. 8.2% in the angiography group (p = 0.45).

Secondary outcomes:

  • Stent thrombosis: 0.5% in the OCT group vs. 1.4% in the angiography group (p = 0.45)


Among patients undergoing coronary revascularization, OCT-guided PCI resulted in a small improvement in acute minimal stent area; however, this did not improve clinical outcomes compared with angiography-guided PCI.


Ali ZA, Landmesser U, Maehara A, et al., on behalf of the ILUMIEN IV Investigators. Optical Coherence Tomography–Guided Versus Angiography-Guided PCI. N Engl J Med 2023;Aug 27:[Epub ahead of print].

Presented by Dr. Ziad Ali at the European Society of Cardiology Congress, Amsterdam, Netherlands, August 27, 2023.

Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Aortic Surgery, Interventions and ACS, Interventions and Imaging, Angiography, Nuclear Imaging

Keywords: Acute Coronary Syndrome, Computed Tomography, Coronary Angiography, Diagnostic Imaging, ESC Congress, ESC23, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Percutaneous Coronary Intervention, Stents, Tomography, Optical Coherence

< Back to Listings