The impact of OCT-guided coronary stent implantation on clinical outcomes in patients with acute coronary syndrome

Background Evidence regarding the prognostic impact of optical coherence tomography (OCT) guidance in patients with acute coronary syndrome (ACS), particularly those without complex angiographic lesions, remains limited. Purpose To determine the impact of OCT-guided versus angiography-guided stent implantation on clinical outcomes in ACS patients. Methods Between January 2023 and October 2023, 1668 ACS patients who underwent coronary stent implantation were retrospectively enrolled. Patients were divided into the OCT-guided group (n=998) and the angiography-guided group (n=670) based on whether OCT imaging alone was used during PCI. The primary endpoint was 2-year major adverse cardiovascular events (MACE), including cardiac death, non-fatal myocardial infarction, and ischemia-driven revascularization. Subgroup analysis was performed based on the presence of complex coronary lesions (as defined in the RENOVATE-COMPLEX-PCI study). Results The mean age of all patients was 62.4±10.4 years, with 67.1% were male. Compared with the angiography-guided group, the OCT-guided group had fewer stents implanted, larger stent and post-dilation balloon diameters, and higher post-dilation rates (all P<0.05). The OCT-guided group had a significantly lower incidence of 2-year MACE than the angiography-guided group (6.6% vs. 13.0%, P<0.001), primarily attributed to a significantly lower incidence of cardiac death (1.5% vs. 7.5%, P<0.001) and non-fatal myocardial infarction (0.5% vs. 2.4%, P=0.001) in the OCT-guided group. After adjustment for clinical and angiographic characteristics, multivariate Cox regression analyses showed that OCT guidance was independently associated with a reduced risk of 2-year MACE (HR=0.53, 95%CI: 0.37-0.76), non-fatal myocardial infarction (HR=0.23, 95%CI: 0.08-0.62), cardiac death (HR=0.35, 95%CI: 0.17-0.71), and all-cause death (HR=0.49, 95%CI: 0.28-0.84) compared to angiography guidance. Subgroup analysis demonstrated that OCT guidance, compared with angiography guidance, significantly reduced the incidence of 2-year MACE in both the complex lesion group (8.2% vs. 17.5%, P<0.001) and the non-complex lesion group (5.4% vs. 10.1%, P=0.003), with P for interaction=0.526. After adjustment for clinical and other angiographic characteristics, the results remained consistent. Conclusion Compared with angiography guidance, OCT-guided stent implantation significantly reduced the risk of 2-year MACE in ACS patients, regardless of the presence of complex lesions.