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OCT vs. Angiography to Guide PCI
Study Questions:
What is the effect on long-term survival of using optical coherence tomography (OCT) during percutaneous coronary intervention (PCI)?
Methods:
The investigators conducted a cohort study based on the Pan-London (United Kingdom) PCI registry, which includes 123,764 patients who underwent PCI in National Health Service hospitals in London between 2005 and 2015. Patients undergoing primary PCI or pressure wire use were excluded, leaving 87,166 patients in the study. The primary endpoint was all-cause mortality at a median of 4.8 years. Cox regression analysis was used to estimate hazard ratios (HRs) in the entire population and fully adjusted models, based on covariates (p < 0.05) associated with the outcome.
Results:
OCT was used in 1,149 (1.3%) patients, intravascular ultrasound (IVUS) was used in 10,971 (12.6%) patients, and angiography alone in the remaining 75,046 patients. Overall OCT rates increased over time (p < 0.0001), with variation in rates between centers (p = 0.002). The mean stent length was shortest in the angiography-guided group, longer in the IVUS-guided group, and longest in the OCT-guided group. OCT-guided procedures were associated with greater procedural success rates and reduced in-hospital major adverse cardiac event (MACE) rates. A significant difference in mortality was observed between patients who underwent OCT-guided PCI (7.7%) compared with patients who underwent either IVUS-guided (12.2%) or angiography-guided (15.7%; p < 0.0001) PCI, with differences seen for both elective (p < 0.0001) and acute coronary syndrome subgroups (p = 0.0024). Overall, this difference persisted after multivariate Cox analysis (HR, 0.48; 95% confidence interval [CI], 0.26-0.81; p = 0.001) and propensity matching (HR, 0.39; 95% CI, 0.21-0.77; p = 0.0008; OCT vs. angiography-alone cohort), with no difference in matched OCT and IVUS cohorts (HR, 0.88; 95% CI, 0.61-1.38; p = 0.43).
Conclusions:
OCT-guided PCI was associated with improved procedural outcomes, in-hospital events, and long-term survival compared with standard angiography-guided PCI.
Perspective:
This study reports that OCT guidance during PCI improves short- and long-term outcomes, and is associated with a lower incidence of in-hospital MACE driven mainly by a reduced incidence of myocardial infarction and reduced mortality at long-term follow-up. This was an observational study, associated with the inherent biases of the study design, and needs validation in a prospective randomized blinded study. Furthermore, additional research is indicated to identify the group of patients and lesion types in which OCT guidance during PCI is associated with maximal net clinical benefit.
Keywords: Acute Coronary Syndrome, Angiography, Coronary Angiography, Diagnostic Imaging, Hospital Mortality, Myocardial Infarction, Percutaneous Coronary Intervention, Stents, Survival, Tomography, Optical Coherence, Ultrasonography
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