Comparing intravascular and angiographic imaging strategies for PCI guidance in acute coronary syndromes: a review of reviews

Background Intravascular imaging enhances lesion assessment and stent optimisation during PCI for acute coronary syndromes (ACS). Numerous systematic reviews have compared intravascular imaging with angiography guidance; however, findings are variable and no previous umbrella review has evaluated their methodological quality and consistency. Purpose To synthesise systematic review evidence comparing intravascular-guided versus angiography-guided PCI in ACS, and to appraise review quality and risk of bias. Methods A protocol was registered prospectively (PROSPERO: CRD420251177289). MEDLINE, Embase, PubMed, and Web of Science were searched from inception to October 2025. Eligible studies were systematic reviews/meta-analyses including ACS patients undergoing intravascular imaging-guided PCI compared with angiographic guidance. Primary outcomes were major adverse cardiac events (MACE) and target vessel revascularisation (TVR). Methodological quality was assessed using AMSTAR-2 and risk of bias using ROBIS. All review stages were performed in duplicate. Results A total of 142 records were screened and nine systematic reviews were included. Intravascular imaging was consistently associated with reduced MACE, stent thrombosis, and repeat revascularisation compared with angiography alone. Pooled evidence demonstrated significant reductions in MACE (OR 0.75; 95% CI 0.62–0.90; P = 0.002; Figure 1) and TVR (OR 0.75; 95% CI 0.66–0.85; P < 0.0001; Figure 2). Methodological quality varied widely. Conclusion Across systematic reviews, intravascular imaging is associated with improved clinical outcomes compared with angiography-guided PCI in ACS. However, heterogeneity in review methods and ACS reporting underscores the need for more rigorous evidence synthesis and dedicated trials in high-risk ACS cohorts.