Introduction: Intravascular ultrasound (IVUS) provides intra-procedural guidance in optimizing percutaneous coronary interventions (PCI) and has been shown to improve clinical outcomes in stent implantation. However, current data on the benefit of IVUS during PCI in ST-elevation myocardial infarction (STEMI) patients is mixed. We performed meta-analysis pooling available data assessing IVUS-guided versus angiography-guided PCI in STEMI patients. Methods: We conducted a systematic search on PubMed and Embase for studies comparing IVUS versus angiography-guided PCI in STEMI. Mantel-Haenszel random effects model was used to calculate risk ratios (RRs) with 95% confidence intervals (CIs) for outcomes of major adverse cardiovascular events (MACEs), death, myocardial infarction (MI), target vessel revascularization (TVR), stent thrombosis (ST) and in-hospital mortality. Results: A total of 8 studies including 336,649 individuals presenting with STEMI were included for the meta-analysis. Follow-up ranged from 11 to 60 months. We found significant association between IVUS-guided PCI with lower risk for MACE (RR 0.82, 95% CI 0.76–0.90) compared with angiography-guided PCI. We also found significant association between IVUS-guided PCI with lower risk for death, MI, TVR, and in-hospital mortality but not ST. Conclusion: In our meta-analysis, IVUS-guided compared with angiography-guided PCI was associated with improved long-term and short-term clinical outcomes in STEMI patients.

Intravascular ultrasound (IVUS) provides detailed intra-procedural information to enhance percutaneous coronary intervention (PCI), which has shown improved clinical outcomes with stent implantation compared with those guided solely by angiography [1]. IVUS is useful in vessel and lesion characterization, helping improve stent sizing, apposition and expansion and monitor for complications like edge dissection [2]. Both contemporary European and North American guidelines on coronary revascularization recommend the use of IVUS in PCI, especially cases involving the left main artery and restenosis (class IIa, level of evidence B) [3, 4]. Based on the recent 2023 European Society of Cardiology Guidelines for the management of acute coronary syndrome, use of intravascular imaging with either IVUS or optical coherence tomography (OCT) should be considered to guide PCI (class IIa, level of evidence A) when culprit lesion is clear and may be considered in cases of ambiguous culprit lesions (class IIb, level of evidence C) [5]. Accumulating evidence further suggests that IVUS guidance of PCI in the setting of acute myocardial infarction (AMI) also confers improvement in clinical outcomes compared with angiographic guidance alone [6]. Within this patient population, individuals presenting with ST-elevation myocardial infarction (STEMI) represent the highest acuity patients requiring immediate intervention to reduce risk for significant morbidity and mortality. Existing data are more mixed regarding the utility of IVUS to aid with revascularization in the setting of STEMI and prior meta-analysis on IVUS guidance in AMI have not focused on STEMI. Therefore, the aim of this meta-analysis was to determine whether IVUS is associated with improved clinical outcomes during PCI of STEMI patients.

Search Strategy

A systematic review was performed independently by two physician-reviewers (J.K. and X.J.) within PubMed and Embase databases for studies published prior to May 2023. Key search terms used included “intravascular ultrasound,” “IVUS,” “ST elevation myocardial infarction,” and “acute myocardial infarction.” References of relevant studies were also reviewed for potential studies. Informed consent and Ethics Committee approval was not required for this study.

Study Selection

We reviewed all prospective, retrospective cohort studies and randomized trials that included data comparing IVUS-guided versus angiography-guided PCI in patients presenting with STEMI. Duplicates were removed. We excluded studies on AMI where separate data on STEMI and NSTEMI were not provided. There were studies that included individuals from the same registry – i.e., KAMIR registry. In these cases, the most recent study with relevant data was included for meta-analysis. Only English-language publications were reviewed and included. The Newcastle-Ottawa scale was used to assess quality of cohort studies.

Data Extraction

Baseline characteristics and clinical outcomes were extracted from each study and input into Microsoft Excel by authors J.K. and X.J. Efficacy outcomes included major adverse cardiac events (MACEs), death, myocardial infarction (MI), target vessel revascularization (TVR), stent thrombosis (ST), and in-hospital mortality (Table 1). In studies where propensity matching was performed, we used data provided for the propensity-matched groups. Data from the longest follow-up time were included. As some studies included all-cause death and some cardiovascular death, we included both definitions in the death outcome. With respect to ST, only definite ST events were included if specified in the studies.

Table 1.

Definition of clinical outcomes from included studies

Study nameMajor adverse cardiovascular eventDeathMITVRST
Youn et al. [7] 2011 Composite of death, MI, and target lesion revascularization All-cause Elevation in CK-MB ≥2x ULN (5 ng/mL) or new ST elevation in 2 contiguous leads after discharge Percutaneous or surgical revascularization of the stented lesion, including 5-mm margin segments, and more proximal or distal newly developed lesions Presence of an acute coronary syndrome with angiographic or autopsy evidence of thrombus or occlusion 
Witzenbichler et al. [2] 2014 Composite of cardiac death, MI, or definite/probable ST *** Periprocedural MI: CK >2 ULN with positive CK-MB or troponin I or T. If the total CK not available, then CK-MB >3x ULN. If neither CK nor CK-MB was available, then troponin >5x the 99th percentile of ULN. MI unrelated to the PCI: (1) typical rise and fall of troponin or CK-MB with either ischemic symptoms, development of new pathological Q-waves, or ECG changes indicative of ischemia; (2) development of new pathological Q-waves; or (3) pathological findings of an acute MI. *** Presence of an acute coronary syndrome with angiographic or autopsy evidence of thrombus or occlusion (definite); or unexplained death 30 days after the procedure or AMI involving the target vessel territory without angiographic confirmation (probable) 
Wang et al. [8] 2015 Composite of cardiac death, recurrent MI, target vascular revascularization, or intractable myocardial ischemia *** *** *** *** 
Nakatsuma et al. [9] 2016 All-cause death, MI, or TVR All-cause death Either new abnormal Q-wave or predefined enzymatic changes, or repeat revascularization by coronary stenting or bypass surgery Repeated percutaneous or surgical coronary revascularization owing to restenosis or thrombosis of the culprit vessel Thrombosis at culprit lesions, confirmed on angiography or pathology 
Ya’qoub et al. [10] 2020 *** By diagnosis code By diagnosis code *** *** 
Megaly et al. [11] 2020 *** In-hospital *** *** *** 
Choi et al. [12] 2021 Cardiovascular death, MI, and target lesion revascularization Cardiovascular death Elevated cardiac marker(s) with evidence of ischemia such as a typical symptom, electrocardiographic changes, or appropriate anatomical or functional results *** *** 
Kim et al. [13] 2021 Cardiac death, MI, repeat TVR, and ST Cardiac death *** *** *** 
Study nameMajor adverse cardiovascular eventDeathMITVRST
Youn et al. [7] 2011 Composite of death, MI, and target lesion revascularization All-cause Elevation in CK-MB ≥2x ULN (5 ng/mL) or new ST elevation in 2 contiguous leads after discharge Percutaneous or surgical revascularization of the stented lesion, including 5-mm margin segments, and more proximal or distal newly developed lesions Presence of an acute coronary syndrome with angiographic or autopsy evidence of thrombus or occlusion 
Witzenbichler et al. [2] 2014 Composite of cardiac death, MI, or definite/probable ST *** Periprocedural MI: CK >2 ULN with positive CK-MB or troponin I or T. If the total CK not available, then CK-MB >3x ULN. If neither CK nor CK-MB was available, then troponin >5x the 99th percentile of ULN. MI unrelated to the PCI: (1) typical rise and fall of troponin or CK-MB with either ischemic symptoms, development of new pathological Q-waves, or ECG changes indicative of ischemia; (2) development of new pathological Q-waves; or (3) pathological findings of an acute MI. *** Presence of an acute coronary syndrome with angiographic or autopsy evidence of thrombus or occlusion (definite); or unexplained death 30 days after the procedure or AMI involving the target vessel territory without angiographic confirmation (probable) 
Wang et al. [8] 2015 Composite of cardiac death, recurrent MI, target vascular revascularization, or intractable myocardial ischemia *** *** *** *** 
Nakatsuma et al. [9] 2016 All-cause death, MI, or TVR All-cause death Either new abnormal Q-wave or predefined enzymatic changes, or repeat revascularization by coronary stenting or bypass surgery Repeated percutaneous or surgical coronary revascularization owing to restenosis or thrombosis of the culprit vessel Thrombosis at culprit lesions, confirmed on angiography or pathology 
Ya’qoub et al. [10] 2020 *** By diagnosis code By diagnosis code *** *** 
Megaly et al. [11] 2020 *** In-hospital *** *** *** 
Choi et al. [12] 2021 Cardiovascular death, MI, and target lesion revascularization Cardiovascular death Elevated cardiac marker(s) with evidence of ischemia such as a typical symptom, electrocardiographic changes, or appropriate anatomical or functional results *** *** 
Kim et al. [13] 2021 Cardiac death, MI, repeat TVR, and ST Cardiac death *** *** *** 

***Definition not available or not provided.

MI, myocardial infarction; CK, creatinine kinase; ULN, upper limit of normal.

Data Analysis and Synthesis

We used the Mantel-Haenszel random effects models to calculate risk ratios (RRs) with 95% confidence interval (CI) comparing clinical outcomes of IVUS-guided versus angiography-guided PCI in patients with STEMI. Effect size with p < 0.05 considered statistically significant. Heterogeneity was assessed using the Cochrane’s Q and Higgins’ I2 statistic, with an I2 > 50% considered significant heterogeneity. Risk of biases was assessed using visual inspection of funnel plots. Meta-analysis was performed using Review Manager version 5.4.1 software.

Baseline Characteristics

After systematic review, a total of 8 studies fulfilled our inclusion criteria [2, 7‒13] (Fig. 1). Overall, 336,649 individuals were included in the meta-analysis. There were seven studies with long-term follow-up, which ranged from 11 to 60 months. One study only had data on in-hospital outcomes. Moreover, seven studies had available full-text manuscripts and one had published abstract only. A majority of the studies included were conducted in Asian countries. Baseline characteristics for individual studies are summarized in Table 2.

Fig. 1.

PRISMA diagram of systematic review.

Fig. 1.

PRISMA diagram of systematic review.

Close modal
Table 2.

Baseline characteristics of included studies

Study nameTotal, NIVUS, nNo IVUS, nYearsFollow-up time (months)LocationStudy typeAgeMenHTNDMPrior MIDES%
IVUSno IVUSIVUSno IVUSIVUSno IVUSIVUSno IVUSIVUSno IVUSIVUSno IVUS
Youn et al. [7] 2011 367 134 233 2003–2008 36 South Korea Prospective cohort 60 61.4 74.4 63 50.4 51.4 27.2 32.9 9.6 100 100 
Witzenbichler et al. [2] 2014 813 421 392 2008–2010 12 USA, Germany Prospective cohort NA NA NA NA NA NA NA NA NA NA 100 100 
Wang et al. [8] 2015 80 42 38 2012–2013 12 China Randomized trial 56.4 53.7 60.5 66.7 39.5 23.8 21.1 11.9 NA NA NA NA 
Nakatsuma et al. [9] 2016 3,028 932 2096 2005–2007 60 Japan Prospective cohort 65.9 67.4 75 75 77 81 77 81 6.8 7.7 39 11 
Ya’qoub et al. [10] 2020 65,872 2,755 63,117 2012–2017 11 USA Retrospective cohort 61.04 62.37 74.1 71 61.4 63 27.8 28.5 12.2 9.8 NA NA 
Megaly et al. [11] 2020 252,970 14,015 238,955 2016–2017 In-hospital USA Retrospective cohort 62 overall 71.4 overall NA NA NA NA 12.8 10.6 NA NA 
Choi et al. [12] 2021 5,390 1,053 4,337 2004–2014 48 South Korea Retrospective cohort NA NA NA NA NA NA NA NA NA NA 100 100 
Kim et al. [13] 2021 8,129 1,544 6,585 2005–2018 12 South Korea Prospective cohort NA NA NA NA NA NA NA NA NA NA 100 100 
Study nameTotal, NIVUS, nNo IVUS, nYearsFollow-up time (months)LocationStudy typeAgeMenHTNDMPrior MIDES%
IVUSno IVUSIVUSno IVUSIVUSno IVUSIVUSno IVUSIVUSno IVUSIVUSno IVUS
Youn et al. [7] 2011 367 134 233 2003–2008 36 South Korea Prospective cohort 60 61.4 74.4 63 50.4 51.4 27.2 32.9 9.6 100 100 
Witzenbichler et al. [2] 2014 813 421 392 2008–2010 12 USA, Germany Prospective cohort NA NA NA NA NA NA NA NA NA NA 100 100 
Wang et al. [8] 2015 80 42 38 2012–2013 12 China Randomized trial 56.4 53.7 60.5 66.7 39.5 23.8 21.1 11.9 NA NA NA NA 
Nakatsuma et al. [9] 2016 3,028 932 2096 2005–2007 60 Japan Prospective cohort 65.9 67.4 75 75 77 81 77 81 6.8 7.7 39 11 
Ya’qoub et al. [10] 2020 65,872 2,755 63,117 2012–2017 11 USA Retrospective cohort 61.04 62.37 74.1 71 61.4 63 27.8 28.5 12.2 9.8 NA NA 
Megaly et al. [11] 2020 252,970 14,015 238,955 2016–2017 In-hospital USA Retrospective cohort 62 overall 71.4 overall NA NA NA NA 12.8 10.6 NA NA 
Choi et al. [12] 2021 5,390 1,053 4,337 2004–2014 48 South Korea Retrospective cohort NA NA NA NA NA NA NA NA NA NA 100 100 
Kim et al. [13] 2021 8,129 1,544 6,585 2005–2018 12 South Korea Prospective cohort NA NA NA NA NA NA NA NA NA NA 100 100 

Clinical Outcomes

Our meta-analysis showed significant association between IVUS-guided PCI with lower risk for long-term MACE compare with angiography-guided PCI in patients presenting with STEMI (RR 0.82, 95% CI 0.76, 0.90). IVUS-guided PCI was also associated with lower risk for death, MI, TVR, and in-hospital mortality compared with angiography-guided PCI. There was no significant difference between IVUS-guided versus angiography-guided PCI with respect to ST (Fig. 2). There was no significant heterogeneity detected in most of the outcomes evaluated with the exception of death, which showed moderate heterogeneity (I2 = 58%).

Fig. 2.

Association between IVUS-guided versus angiography-guided PCI with clinical outcomes in patients presenting with STEMI.

Fig. 2.

Association between IVUS-guided versus angiography-guided PCI with clinical outcomes in patients presenting with STEMI.

Close modal

In sensitivity analysis, we excluded data from the study by Kim et al. as this was a published abstract and we were not able to find an accompanying published full manuscript. Excluding this study did not significantly change the results. Outcomes for MACE (RR 0.80, 95% CI 0.71, 0.91) and TVR (RR 0.79, 95% CI 0.92) remained significant favoring IVUS-guided PCIs compared with angiography-guided PCI. There was a trend favoring IVUS-guided PCI with respect to death (RR 0.62, 95% CI 0.38, 1.01) though significance was attenuated. There remained no difference between IVUS versus angiography-guided PCIs with respect to ST (RR 0.69, 95% CI 0.17, 2.78). We further performed sensitivity analysis excluding studies with bare metal stents use or those that did not provide information on stent type. Results for MACE (RR 0.75, 95% CI 0.65, 0.86) and death (RR 0.17, 0.03, 0.94) remained significant, while association with lower risk for MI (RR 0.95, 95% CI 0.60, 1.50) and TVR (RR 0.97, 95% CI 0.52, 1.82) were attenuated.

The results of our meta-analysis suggest that IVUS-guided PCI has improved outcomes compared to angiography-guided PCI in patients presenting with STEMI with association of lower risk for long-term MACE, including death, MI, TVR, and in-hospital mortality. However, there was no significant difference between IVUS-guided versus angiography-guided PCI in regard to ST. Our findings are similar to prior studies on AMI showing association with improved short-term and long-term outcomes with IVUS-guided compared with angiography-guided PCI [14, 15]. A prior meta-analysis on IVUS in AMI found association with lower MACE, death, and TVR in the IVUS-guided group compared with angiography only group [6]. Here, we further demonstrate that the clinical benefits also extend specifically for PCIs in STEMI patients.

The utility of IVUS in evaluating plaque morphology and guiding stent optimization is relevant in both PCI of stable coronary artery disease as it is in AMI [2]. Yet the absolute benefit of appropriate stent sizing, avoiding geographic miss and edge dissections are further enhanced in the setting of the higher risk milieu (inflammation, cytokine release, procoagulable state) associated with STEMI [16]. Moreover, in STEMI, IVUS may further allow better ascertainment of the location of plaque rupture, which may not always be obvious on angiography alone, ensuring appropriate coverage by stenting. Finally, while our study focused on the use of IVUS on culprit vessels, contemporary evidence supports complete revascularization in STEMI patients with multivessel disease [17]. As such, the additional use of IVUS in PCI of non-culprit vessels may confer additional clinical benefits, though this should be validated in future studies.

Surprisingly, our results did not show association with lower ST in the IVUS-guided group. This result is contrary to findings from large studies including the ULTIMATE trial and ADAPT-DES, showing lower rates of ST among patients treated with IVUS-guided PCI [1, 2]. In the HORIZONS-AMI study, two predictors of definite/probable early ST were inflow/outflow disease (residual stenosis outside stent edge and edge dissections) and minimum lumen cross-sectional area (due to stent under-expansion or significant tissue protrusion) [18]. One would expect by using IVUS, these parameters would be addressed, resulting in lower rates of ST in the IVUS group. However, there was limited information and potential heterogeneity in how IVUS (i.e., pre-PCI, post-PCI, or both) was used in the studies included in our meta-analysis. Additionally, the lack of significant difference between ST could be due to the variability in definition of ST among the different studies as well as the small number of studies that included ST as an outcome.

While our study focuses on IVUS, OCT is the other commonly available intravascular imaging modality used to assess plaque morphology and guide PCI. OCT produces more higher resolution images and may improve diagnosis of the etiology of MI, in particular those not associated with acute plaque rupture such as plaque erosion or spontaneous coronary artery dissections. A small randomized study of STEMI patients showed OCT-guided PCI was associated with less stent implantation and lower residual diameter stenosis compared with angiographic guidance alone [19]. A larger trial examining the efficacy of OCT-guided PCI in STEMI patients is currently underway [20]. Randomized trial data are limited in comparison of IVUS versus OCT in the setting of MI. In the recent OCTIVUS trial, OCT-guided PCI was noninferior to IVUS-guided CI with respect to the composite endpoint of cardiac death, MI, and TVR. However, only ∼10% of the study population included had non-STEMI and STEMI patients were excluded [21].

There were several limitations to our meta-analysis. First, our study pooled data from observational studies, as there are no large randomized trials focused of IVUS use in STEMI patients. Second, studies encompassing drug eluting stents as well as bare metal stents were included. Third, data on stent length and number of stents implanted were limited. Finally, a large number of included studies were conducted in East Asian patients, and it is unclear whether results are generalizable to other patient populations.

In our meta-analysis, IVUS-guided compared with angiography-guided PCI was associated with improved long-term and short-term clinical outcomes in STEMI patients. The use of IVUS should be considered during PCI of patients with AMI, even in those with STEMI. Future randomized trials assessing the utility of IVUS guidance in STEMI PCI are warranted.

An ethics statement is not applicable because this study is based exclusively on published literature.

The authors have no conflicts of interest to declare.

The authors have no relevant funding sources to declare.

J.K. and X.J.: conception/design of work; acquisition, analysis, and interpretation of data; and drafting and revising the manuscript; J.S., S.K., J.L., M.U.K., A.D., M.A., and W.K.: interpretation of data; revising the manuscript. All authors gave final approval of the manuscript and agreed to be accountable for all aspects of the work.

All data generated or analyzed during this study are included in this article. Further inquiries can be directed to the corresponding author.

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