Key result
IVUS-guided PCI reduces cardiac death ~29% versus angiography, with greater benefit in East Asian trials.
Why the study?
Intravascular ultrasound-guided PCI has shown improved outcomes in randomized trials, but recent European trials reported neutral results compared to positive East Asian studies, raising uncertainty about geographic consistency of benefit.
Does IVUS-guided PCI reduce cardiac death compared to angiography-guided PCI in patients undergoing drug-eluting stent implantation, and does this effect vary by geography?
Meta-Analysis (n=14,033)
Yes
Does IVUS-guided PCI reduce cardiac death compared to angiography-guided PCI in patients undergoing drug-eluting stent implantation, and does this effect vary by geography?
IVUS-guided PCI reduces cardiac death and other adverse events compared to angiography guidance, but this benefit is primarily driven by East Asian trials with significant geographic heterogeneity.
Answers are grounded in this paper and cite their sources.
Supports IVUS-guided PCI to reduce cardiac death in DES patients; confirms mortality benefit while highlighting geographic heterogeneity needing validation.
Background and Aims Intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) has improved outcomes in randomized trials, yet some recent European trials reported neutral results despite positive findings from East Asian studies. This study assessed whether benefit was consistent across settings. Methods Randomized trials comparing IVUS-guided with angiography-guided drug-eluting stent PCI were systematically reviewed and meta-analysed. Pooled risk ratios (RRs) used restricted maximum likelihood random-effects models with Hartung–Knapp–Sidik–Jonkman adjustment. Geographic effect modification was pre-specified as the primary hypothesis, and the interaction test for cardiac death was the primary analysis. Results Seventeen trials (14 033 patients; 10 East Asian [10 155], 7 non-Asian [3878]) were included. The pooled RR for cardiac death was.71 (95% confidence interval [CI] .53–.94, P = .022), with a significant geographic interaction: East Asian RR.56 (.46–.69) vs non-Asian RR 1.23 (.85–1.76; interaction P < .001). Treatment effects diverged for target-vessel myocardial infarction (TV-MI; interaction P = .011), target-vessel revascularization (TVR; interaction P = .004), and major adverse cardiovascular events (MACE; interaction P = .040). IVUS guidance reduced definite stent thrombosis (RR .39, 95% CI .19–.79; interaction P = .433). All-cause death was similar (RR .89, 95% CI .76–1.04). Conclusions Considering all studies, IVUS-guided PCI reduced cardiac death, TV-MI, TVR, MACE, and stent thrombosis. However, significant interactions were present such that the relative reductions in cardiac death, TV-MI, TVR, and MACE were greater in the Asian compared with non-Asian trials (although stent thrombosis was reduced consistently across geographies). Differences in how the information derived from IVUS was used to optimize stent implantation may contribute to this geographic heterogeneity.
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Bulluck et al. (2026) conducted a meta-analysis in Percutaneous coronary intervention (n=14,033). Intravascular ultrasound (IVUS)-guided PCI vs. Angiography-guided PCI was evaluated on Cardiac death (RR 0.71, 95% CI 0.53-0.94, p=0.022). IVUS-guided PCI reduced cardiac death versus angiography guidance, with greater benefit in East Asian compared to non-Asian trials.
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