Optical coherence tomography-guided percutaneous coronary intervention in acute coronary syndrome patients with complex lesions: a subgroup analysis of the randomised OCCUPI Trial

The role of optical coherence tomography (OCT) guidance during percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS) remains inconclusive.

This study aimed to evaluate the impact of OCT-guided PCI in ACS patients with complex lesions.

The Optical CoherenCe Tomography-gUided Coronary Intervention in Patients With Complex Lesions (OCCUPI) Trial compared PCI with OCT guidance versus angiography guidance in patients who required drug-eluting stent implantation for complex lesions. This post hoc analysis focused on participants presenting with ACS. The primary outcome was 1-year major adverse cardiac events (a composite of cardiac death, myocardial infarction, stent thrombosis, or ischaemia-driven target vessel revascularisation).

Out of 1,604 randomised patients, 790 (49.3%) and 814 (50.7%) presented with ACS and chronic coronary syndrome (CCS), respectively. Among patients with ACS, the incidence of the primary outcome was 4.9% in the OCT-guided group and 9.5% in the angiography-guided group (hazard ratio [HR] 0.50, 95% confidence interval [CI]: 0.29-0.87; p=0.011). Among patients with CCS, its incidence was 4.4% and 5.4%, respectively (HR 0.80, 95% CI: 0.43-1.50; p=0.479). No significant interaction between clinical presentation and imaging guidance strategy was observed for the primary outcome (p_interaction=0.273). Among patients with ACS randomised to OCT guidance, the achievement of stent optimisation by OCT was associated with a lower incidence of the primary outcome compared with suboptimisation (2.9% vs 9.7%; HR 0.29, 95% CI: 0.12-0.72; p=0.004).

In ACS patients with complex lesions, OCT-guided PCI demonstrated an evident cardiovascular benefit over angiography-guided PCI, a finding endorsed by current guidelines. (ClinicalTrials.gov: NCT03625908).