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Intravascular Imaging to Guide PCI
Quick Takes
- In this select group of patients (aged >65 years; predominantly white men) across a broad clinical spectrum, use of intravascular imaging (IVI) (predominantly IVUS) increased over a span of 6 years (from 9.5% to 15.4%).
- IVI use to guide PCI was associated with lower rates of MACE (aHR, 0.85; 95% CI, 0.84–0.86) and its components including all-cause mortality compared to angiography-guided PCI.
Study Questions:
What are trends in utilization of intravascular imaging (IVI) to guide percutaneous coronary intervention (PCI) and its impact on clinical outcomes in the United States?
Methods:
This was a retrospective cohort study of Medicare beneficiary data from January 1, 2013–December 31, 2019 to evaluate temporal trends and comparative outcomes of IVI-guided PCI as compared with PCI with angiography guidance alone in both the inpatient and outpatient settings. The primary outcomes were 1-year mortality and major adverse cardiovascular events (MACE), defined as the composite of death, myocardial infarction (MI), repeat PCI, or coronary artery bypass graft surgery. Secondary outcomes were MI or repeat PCI at 1 year. Multivariable Cox regression was used to estimate the adjusted association between IVI guidance and outcomes. Falsification endpoints (hospitalized pneumonia and hip fracture) were used to assess for potential unmeasured confounding.
Results:
The study population included 1,189,470 patients undergoing PCI (38.0% female, 89.8% White, 65.1% with MI). Overall, IVI was used in 10.5% of the PCIs, increasing from 9.5% in 2013 to 15.4% in 2019. Operator IVI use was variable, with the median operator use of IVI 3.92% (interquartile range, 0.36%–12.82%). IVI use during PCI was associated with lower adjusted rates of 1-year mortality (adjusted hazard ratio [aHR], 0.96; 95% confidence interval [CI], 0.94–0.98]), MI (aHR, 0.97; 95% CI, 0.95–0.99), repeat PCI (aHR, 0.74; 95% CI, 0.73–0.75), and MACE (aHR, 0.85; 95% CI, 0.84–0.86). There was no association with the falsification endpoint of hospitalized pneumonia (aHR, 1.02; 95% CI, 0.99–1.04) or hip fracture (aHR, 1.02; 95% CI, 0.94–1.10).
Conclusions:
Among Medicare beneficiaries undergoing PCI, use of IVI has increased over the previous decade but remains relatively infrequent. IVI-guided PCI was associated with lower risk-adjusted mortality, acute MI, repeat PCI, and MACE.
Perspective:
In this select group of patients (aged >65 years; predominantly white men) across a broad clinical spectrum, use of IVI (predominantly IVUS) increased over a span of 6 years (from 9.5% to 15.4%). IVI use to guide PCI was associated with lower rates of MACE (26% relative risk reduction) and its components including all-cause mortality compared to angiography-guided PCI. Several randomized controlled trials and observational studies have shown benefit of IVI guidance for PCI; however, use of IVI remains low. Further study to better understand barriers to uptake such as routing practice, regional variations, and racial disparities in IVI use is needed.
Clinical Topics: Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Interventions and Imaging, Echocardiography/Ultrasound
Keywords: Percutaneous Coronary Intervention, Ultrasonography
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