Home Medizin Die intravaskuläre Bildgebung verbessert das Überleben von Patienten mit Herzerkrankungen, die sich einer Stent-Implantation unterziehen

Die intravaskuläre Bildgebung verbessert das Überleben von Patienten mit Herzerkrankungen, die sich einer Stent-Implantation unterziehen

von NFI Redaktion


Using intravascular imaging to guide stent implantation during percutaneous coronary intervention (PCI) in patients with heart disease significantly improves survival rates and reduces adverse cardiovascular events compared to angiography-guided PCI, the most commonly used method.

These are the findings of the largest and most comprehensive clinical study of its kind comparing two types of intravascular imaging procedures (intravascular ultrasound (IVUS) and optical coherence tomography (OCT)) with angiography-guided PCI. The study, published in The Lancet, demonstrates for the first time that these two high-resolution imaging methods can reduce overall mortality, heart attacks, stent thrombosis, and the need for revascularization.

“Our study, representing a synthesis of all early and more recent clinical studies, has demonstrated for the first time that routine use of intravascular imaging guidance improves survival, and enhances all aspects of safety and efficacy of coronary stenting, even with outstanding contemporary drug-eluting stents.”

Gregg W. Stone, MD, Lead Author

Dr. Stone is the Director of Academic Affairs for the Mount Sinai Health System and a Professor of Medicine (Cardiology) and Population Health Science and Policy at the Icahn School of Medicine at Mount Sinai.

“Previous studies had shown benefits of intravascular imaging, but never to this extent,” adds Dr. Stone. “The addition of four recently conducted trials, involving 7,224 patients, now demonstrates that intravascular imaging reduces overall mortality and all heart attacks in a broad spectrum of patients undergoing stent treatment. Therefore, routine use of intravascular imaging for stent placement is one of the most effective therapies we have to improve the prognosis of patients with coronary heart disease.”

Patients with coronary heart disease – plaque buildup in the arteries leading to chest pain, shortness of breath, and heart attack – often undergo PCI, a non-surgical procedure in which interventional cardiologists use a catheter to place stents in the clogged coronary arteries to restore blood flow. Interventional cardiologists most commonly use angiography to guide PCI, in which a special dye (contrast) and X-rays are used to visualize how blood flows through the heart arteries and identify any blockages.

However, angiography has limitations, making it difficult to determine the actual artery size and plaque characteristics and not optimal for assessing complete stent expansion following PCI and identifying other conditions affecting the early and late outcomes of the PCI procedure. Intravascular ultrasound was introduced over 30 years ago to provide accurate and specific images of the coronary arteries. Although studies have shown that IVUS-guided PCI is superior to angiography-guided PCI and reduces cardiovascular events, it is only used in about 15 to 20 percent of PCI cases in the United States, as the images may be difficult to interpret and the procedure is not fully reimbursed.

Optical coherence tomography uses light instead of sound to create images of blockages. OCT images have much higher resolution, more accurate and detailed images compared to IVUS, and are easier to interpret. However, OCT is only used in 3 percent of PCI cases as it is considered a newer technique with limited study data – a limitation that this new study has addressed.

In their study, the researchers analyzed data from 15,964 patients undergoing PCI from 22 studies in hundreds of centers in the US, Europe, Asia, and elsewhere between March 2010 and August 2023. Patients underwent either angiography-guided PCI or intravascular imaging-guided PCI using IVUS or OCT. During a follow-up period of 6 to 60 months with a mean of two years, patients receiving intravascular imaging support experienced a 25 percent reduction in overall mortality, a 45 percent reduction in cardiac death, a 17 percent reduction in all myocardial infarctions, and a 48 percent reduction in stent thrombosis compared to angiography guidance. The study also found that intravascular imaging reduced target vessel myocardial infarction by 18 percent and target lesion revascularization by 28 percent. The results were similar for both OCT-guided and IVUS-guided PCI.

“Given these results, we must now shift from conducting no more trials to ascertain the benefit of intravascular imaging to greater efforts to overcome the remaining barriers to the routine use of OCT and IVUS, including better training of physicians and staff and increased cost reimbursement,” said Dr. Stone. “In this regard, we now have better ‘hard evidence’ that intravascular imaging guidance in PCI procedures has a greater impact on improving the lives of our patients than other routine therapies that are more commonly used and reimbursed.”

Source:

Mount Sinai Health System

Journal Reference:

Stone, GW, et al. (2024). Intravascular imaging drug-eluting stent implantation in the coronary area: an updated network meta-analysis. The Lancet. doi.org/10.1016/S0140-6736(23)02454-6.

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