Intravascular imaging vs. angiography alone to guide percutaneous coronary intervention in older adults: a meta-analysis of randomized controlled trials

Abstract

Background

Older adults undergoing percutaneous coronary intervention (PCI) face unique challenges due to complex anatomy and comorbidities. Intravascular imaging [including intravascular ultrasound (IVUS) and optical coherence tomography (OCT)] has been shown to improve PCI outcomes, but its benefits in older adults are less well established. We conducted a meta-analysis of randomized controlled trials (RCTs) to compare intravascular imaging with angiography alone to guide PCI in older adults.

Methods

Cochrane, PubMed, and Scopus were searched for RCTs comparing intravascular imaging (IVUS or OCT) vs. angiography alone in adults aged ≥65 years. The outcome of interest was major adverse cardiovascular events (MACE) at the longest follow-up, as defined by each trial. Subgroup analyses were performed based on intravascular imaging modality, age group, and lesion complexity. Data were pooled using random-effects models, and heterogeneity was assessed using Higgins’ I² statistic.

Results

Nine RCTs (n = 7164, intravascular imaging = 3703, angiography alone = 3461) met the inclusion criteria. Intravascular imaging significantly reduced MACE compared with angiography alone [relative risk (RR) 0.66, 95% confidence interval (CI) 0.56–0.77; P < 0.001; I² = 0%]. IVUS demonstrated superiority over angiography alone (RR 0.55, 95% CI 0.43–0.72; P < 0.001; I² = 0%), while OCT demonstrated only a trend toward MACE reduction (RR 0.80, 95% CI 0.62–1.02). Subgroup analyses indicated consistent benefits with intravascular imaging for adults aged ≥65 and ≥70 years, respectively, and among those with complex coronary lesions (RR 0.65, 95% CI 0.53–0.79; P < 0.001).

Conclusion

Intravascular imaging guidance, especially IVUS, reduces MACE in older adults undergoing PCI compared with angiography alone.

Introduction

As the USA (US) population continues to age, more older adults with coronary artery disease (CAD) are undergoing percutaneous coronary intervention (PCI) [1]. This older demographic often presents with unique profiles, like frailty, multiple comorbidities, and complex coronary anatomy that can complicate their treatment [1]. Optimizing outcomes in this population may require precision guidance during PCI [2,3].

PCI has traditionally relied on angiographic guidance, which only provides a two-dimensional visualization of the coronary arteries. Although angiography is widely used and effective, it can fail to capture some key plaque features that may impact stent sizing, placement, and expansion. Technological advancement has introduced intravascular imaging modalities such as intravascular ultrasound (IVUS) and optical coherence tomography (OCT). IVUS and OCT provide high-resolution, three-dimensional imaging, allowing for more accurate assessment of lesions and stent deployment [4]. Although prior meta-analyses have shown benefits with intravascular imaging guidance for CAD patients undergoing PCI, data focused on the older population are lacking [5–7]. Older adults often present with more complex coronary anatomy characterized by extensive atherosclerotic plaque burden, calcifications, vessel tortuosity, ostial lesions, multivessel disease, and left main stenosis that may benefit from these advanced imaging modalities [1,3]. However, their higher rates of multimorbidity increased procedural complexity, and the potential for adverse events may lead to poor tolerance of extended procedures and lower utilization of intravascular imaging, raising concerns about whether the same benefits observed in younger, lower-risk patients extend to older individuals [2,8].

Despite recent guidelines from leading US and European cardiology societies recommending intravascular imaging for stent optimization in selected patient populations, no specific guidance exists for older patients [9,10]. Older adults remain underrepresented in randomized trials to date, which limits the detection of potential age-related variability of treatment effects across individual studies [11,12]. Therefore, we sought to perform a meta-analysis of randomized controlled trials (RCTs) comparing outcomes for older patients with CAD (presenting with either acute or chronic coronary syndromes) and undergoing PCI with intravascular imaging vs. angiography alone to evaluate whether the benefits of intravascular imaging seen in younger populations extend to older adults.

Methods

This systematic review and meta-analysis were conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 (PRISMA) guidelines [13] and were registered with the International Prospective Register of Systematic Reviews (PROSPERO; registration number CRD42025642209). The study was granted exempt status by the University of Massachusetts–Baystate Medical Center Institutional Review Board, as it used publicly available, deidentified data.

Data sources and search strategy

Two independent reviewers (C.E. and S.I.) conducted a systematic search of PubMed, Scopus, and the Cochrane Central Register of Controlled Trials databases from their inception through January 2025 to identify RCTs comparing IVUS or OCT with angiography alone to guide PCI in older adults (≥65 years). Both Medical Subject Headings and free-text terms were used to ensure a comprehensive search. Key terms included ‘optical coherence tomography’, ‘intravascular ultrasound’, ‘intravascular imaging’, ‘angiography’, ‘percutaneous coronary intervention’, ‘stent’, and ‘randomized controlled trials’. No restrictions were applied regarding language, publication date, or sample size. Detailed search strategies for each database are available in Supplementary Table 1, Supplemental digital content 1, https://links.lww.com/MCA/A779.

Defining older adults

We defined ‘older adults’ as those ≥65 years, consistent with American Geriatric Society criteria [14]. The set-point of 65 years can be traced to the Social Security Act of 1935, which established 65 years as the age of eligibility for federal retirement benefits [15]. This age threshold of 65 years has been incorporated to define older adults in clinical trials as well as to perform subgroup analyses of older adults. However, due to advancements in healthcare, changing patient demographics, and new perceptions of aging, there has been a growing movement to redefine the older adult as being aged 75 years or greater [16,17]. Some clinical trials have begun to adopt 75 years or older to define the older population. This change is evident in bleeding risk scores such as the PARIS bleeding score and the PRECISE-DAPT score, which recognize age ≥75 years as a criterion for high bleeding risk [18,19]. We performed our meta-analysis using 65 years as our primary set point while also performing a subgroup analysis of patients aged ≥70 years and those aged ≥75 years if the outcome of interest was available in at least two included RCTs.

Outcomes

The primary outcome was major adverse cardiac events (MACE), a composite of cardiac death, myocardial infarction (MI), and any revascularization. Subgroup analyses were performed, stratifying the study population by imaging modality (OCT or IVUS) or age group [≥65, ≥70, or ≥75 years old (when reported by at least 2 included studies)], and a separate analysis was conducted of older adults with complex coronary lesions. Additionally, MACE outcomes were compared between patients aged ≥65 years and those aged <65 years who underwent intravascular imaging-guided PCI.

Study selection and eligibility criteria

Two authors (C.E. and S.I.) independently screened and evaluated all identified studies, resolving any discrepancies through discussion or with input from a third author (M.M.K.). Studies were eligible for inclusion in the primary analysis if they met the following criteria: (1) RCTs comparing IVUS- or OCT-guided PCI with angiography alone; (2) use of drug-eluting stents; and (3) either included only patients aged 65 years and above or reported age-specific subgroup data for MACE. Exclusion criteria included (1) nonrandomized studies, observational studies, conference abstracts, or case reports; and (2) studies that exclusively included patients under the age of 65 or failed to provide age-specific MACE data. Studies utilizing IVUS or OCT were included regardless of lesion complexity or the clinical indication for PCI [acute coronary syndrome (ACS) or chronic coronary syndrome]. Additionally, studies that randomized patients to receive intravascular imaging alongside alternative imaging or physiology-based guidance methods other than angiography were excluded.

Data extraction and evaluation of study quality

Two authors (C.E. and S.I.) independently extracted data using prespecified tables. Extracted variables included baseline characteristics, definitions of MACE, event counts, and intravascular imaging modality (IVUS or OCT). The methodological quality of the included studies was assessed using the Cochrane Collaboration’s Risk of Bias Tool for RCTs [20].

Data synthesis and statistical analysis

All statistical analyses were conducted using Cochrane Review Manager (RevMan) software, version 5.3 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark, 2014). Risk ratios (RRs) with 95% confidence intervals (CIs) were calculated using the Inverse variance method for study weighting. To assess statistical heterogeneity, Higgins’ I² statistic was applied, with values greater than 50% indicating moderate to substantial heterogeneity [21]. Random-effect models were used to generate pooled effect estimates, incorporating the DerSimonian–Laird method to account for between-study variability [22]. For outcomes demonstrating significant heterogeneity (I² >50%), a leave-one-out sensitivity analysis was planned using R statistical software, version 4.3.2 (R Foundation for Statistical Computing, Vienna, Austria), whereby each study was sequentially excluded to determine its influence on the overall results and identify potential outliers. We also performed further sensitivity analyses to address heterogeneity in MACE definition across studies. This was achieved by performing separate analysis for studies that reported MACE as target vessel failure (TVF), a composite of cardiac death, target vessel-MI, and target vessel revascularization (TVR), as well as those that reported MACE as target lesion failure (TLF), a composite of cardiac death, target lesion-MI, and target lesion revascularization. Publication bias was evaluated through visual inspection of funnel plots. Certainty of evidence for each outcome was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Five domains were considered: risk of bias, inconsistency, indirectness, imprecision, and publication bias. Evidence was rated as high, moderate, low, or very low certainty. The authors confirm that all supporting data are available within the article for reproducibility of findings.

Results

Systematic review

The initial database search yielded 2151 records. After removing 1422 duplicates, 729 studies underwent title and abstract screening, of which 694 were excluded for not meeting the inclusion criteria. A full-text review was conducted for the remaining 35 studies, leading to the exclusion of 26 additional studies. Notably, the FLAVOUR and FORZA trials, which evaluated IVUS and OCT, respectively, were excluded due to the use of fractional flow reserve-guided PCI in the control arm rather than angiography alone [23,24]. Ultimately, nine RCTs met the eligibility criteria and were included in the quantitative synthesis [25–33]. A detailed overview of the study selection process is presented in Supplementary Fig. 1, Supplemental digital content 1, https://links.lww.com/MCA/A779.

Study population and baseline characteristics

Nine RCTs involving 7164 older patients with CAD (presenting with acute or chronic coronary syndromes) were included [25–33]. Of these, 3703 patients underwent intravascular imaging-guided PCI, while 3461 underwent PCI guided by angiography alone. Follow-up ranged from 1 to 5 years, with a weighted mean follow-up of 1.9 years (Table 1). Eight of the nine RCTs provided subgroup data for older patients [25–32]. One RCT exclusively included patients aged 70 years or older [33] while one RCT provided subgroup data for patients aged ≥75 years [26]. Five RCTs used IVUS [25,26,30,32,33], three used OCT [28,29,31,34], and one used both IVUS and OCT to guide PCI [27]. Four RCTs included only patients with complex coronary lesions [27,28,31,33], one RCT reported subgroup data for complex lesions [34], and one RCT focused exclusively on patients presenting with ACS [30]. Baseline comorbidities, such as hypertension, diabetes, and dyslipidemia, were balanced between the intravascular imaging- and angiography-guided groups (Table 2). Definitions of MACE varied across studies. While some defined MACE as a composite of cardiac death, MI, and TVR [25,28,31,33], others used TVF, a composite of cardiac death, target vessel MI, and ischemia-driven TVR [26,27,29,30].

Table 1.

Characteristics of included studies

Study	Year	Comparison	Location	Number of centers	Sample size (ICA/IVI)	Follow-up (months)	Stent type	MACE definition
Tan et al. [33]	2015	ICA vs. IVUS	East Asia	Single center	123 (62/61)	24	Sirolimus-eluting stents (Firebird-2, Microport, Shanghai, China) or sirolimus-eluting stents (Excel, Jiwei, Shandong, China)	Death, nonfatal myocardial infarction, or target lesion revascularization
IVUS-XPL [25]	2020	ICA vs. IVUS	East Asia	Multicenter	1400 (700/700)	60	Everolimus-eluting stent	Cardiac death, target lesion-related myocardial infarction, or ischemia-driven target lesion revascularization
ULTIMATE [26]	2021	ICA vs. IVUS	East Asia	Multicenter	1448 (724/724)	36	Second-generation DES	Cardiac death, target vessel myocardial infarction, and clinically driven target vessel revascularization
RENOVATE-COMPLEX-PCI [27]	2023	ICA vs. IVI	East Asia	Multicenter	1639 (547/1092)	36	Polymer-coated everolimus-eluting stents	Cardiac death, target vessel-related myocardial infarction, or clinically driven target vessel revascularization
OCTOBER [28]	2023	ICA vs. OCT	Europe	Multicenter	1201 (601/600)	24	Xience everolimus-eluting stent (other newer-generation stents used only when the Xience stent was not available)	Cardiac death, target lesion myocardial infarction, or ischemia-driven target lesion revascularization
ILUMIEN IV [29,34]	2024	ICA vs. OCT	Europe, North America, Oceania, and East Asia	Multicenter	2487 (1254/1233)	24	Biocompatible polymer-coated everolimus-eluting stents (XIENCE, Abbott Vascular)	Cardiac death, target vessel myocardial infarction, or ischemia-driven target vessel revascularization
IVUS ACS [30]	2024	ICA vs. IVUS	Asia and Europe	Multicenter	3505 (1752/1753)	12	Second-generation DES	Cardiac death, target vessel myocardial infarction, or clinically driven target vessel revascularization
OCCUPI [31]	2024	ICA vs. OCT	South Korea	Multicenter	1604 (801/803)	12	Everolimus-eluting stents (XIENCE Alpine or XIENCE Sierra, Abbott Vascular, Chicago, Illinois, USA)	Cardiac death, myocardial infarction, stent thrombosis, or ischemia-driven target-vessel revascularization
GUIDE DES [32]	2024	QCA vs. IVUS	Korea	Multicenter	1528 (763/765)	12	DES	Cardiac death, target vessel myocardial infarction, or ischemia-driven target lesion revascularization

DCB, drug-coated balloon; DES, drug-eluting stent; ICA, invasive coronary angiography; IVI, intravascular imaging; IVUS, intravascular ultrasound; OCT, optical coherence tomography; PCI, percutaneous coronary intervention.

Table 2.

Baseline characteristics of included studies

Study, year	Comparison	Male, %	HTN, %	Dyslipidemia	DM	Current smoker	LVEF, %	Prior MI	Prior PCI	Prior CABG	Stable angina	UA	AMI
Tan et al. [33]	IVUS vs. Angio	62/70	41/46.8	NA	34.4/29.5	44.3/46.8	55.32/53.33	16.4/21	NA	NA	30/34	71/66	NA
IVUS-XPL [25]	IVUS vs. Angio	69/69	65/63	67/65	32/38	22/23	62.8/62.3	5/5	11/10	3/3	49/52	36/32	15/17
ULTIMATE [26]	IVUS vs. Angio	73.9/73.2	70.7/72	53.7/55.2	30/31.2	NA	NA	NA	NA	NA	NA	NA	78.6/78.3
RENOVATE-COMPLEX-PCI [27]	IVI vs. Angio	79.6/78.8	62.5/59	51.3/51.2	39/45	19.4/17.4	58.4/59.3	6.9/7.7	24.5/23.2	N/A	48.7/50.3	33.1/31.6	36.7/35.9
OCTOBER [28]	OCT vs. Angio	78.8/79	70.3/74.5	76/78.4	17.2/16.1	12.8/14.1	59.5/58	28.3/30	40.7/42.8	1.2/1.5	55/53.4	8.8/9.7	36.2/37
ILUMIEN IV [29,34]	OCT vs. Angio	78.5/76.2	71.4/74.0	65.5/68.6	42.4/41.5	19.6/19.7	55.2/55.2	20.4/24.2	13.3/13.4	5.1/4.2	27/28.5	28.8/26.4	30.2/29.6
IVUS ACS [30]	ICA vs. IVUS	73.3/74.1	62.9/62.2	67.7/69.8	31.6/31.5	28.5/27.8	62/62	8.7/8.8	10.2/10.2	0.2/0.2	0/0	39.9/41.4	60.1/58.6
OCCUPI [31]	OCT vs. Angio	80/80	58/56	85/83	3/4	19/20	59.5/59.7	40/42	21/20	1/2	49/53	31/27	21/20
GUIDE DES [32]	QCA vs. IVUS	75.2/81.3	62.9/63.8	85.8/84.8	33.7/31.0	26.6/23.3	NA	6.2/7.3	15.3/15.6	0.9/0.8	71.3/70.3	NA	28.7/29.7

Data is presented as mean or percent.

AMI, acute myocardial infarction; Angio, angiography; CABG, coronary artery bypass grafting; CKD, chronic kidney disease; DM, diabetes mellitus; HTN, hypertension; IVI, intravascular imaging; IVUS, intravascular ultrasound; LVEF, left ventricular ejection fraction; MI, myocardial infarction; NA, not available; OCT, optical coherence tomography; PCI, percutaneous coronary intervention; UA, unstable angina.

Outcomes

This meta-analysis found that intravascular imaging-guided PCI significantly reduced MACE compared with angiography alone in older patients (RR 0.66, 95% CI 0.56–0.77; P < 0.001; I² = 0%; Fig. 1). Older patients with complex coronary lesions experienced a reduction in MACE risk with intravascular imaging-guided PCI compared with angiography alone (RR 0.65, 95% CI 0.53–0.79; P < 0.001; I² = 0%) (Fig. 1). Subgroup analysis by intravascular imaging modality revealed a notable reduction in MACE with IVUS guidance (RR 0.55, 95% CI 0.43–0.72; P < 0.001; I² = 0%), while OCT showed a trend toward MACE reduction (RR 0.80, 95% CI 0.62–1.02; P = 0.07; I2 = 0%; P_interaction = 0.04) compared with angiography alone (Fig. 2). Age-based subgroup analysis demonstrated that intravascular imaging guidance reduced MACE in patients older than 65 and 70 years when compared with angiography alone (P_interaction = 0.29 for age) (Fig. 3). There was no difference in risk of MACE between patients aged ≥65 years and those aged <65 years who underwent intravascular imaging-guided PCI (RR 1.04, 95% CI 0.86–1.26; P = 0.71; I² = 0%) (Fig. 4).

Fig. 1.

Risk ratios for major adverse cardiovascular events in patients aged ≥65 years undergoing intravascular imaging-guided percutaneous coronary intervention vs. angiography alone for: (a) Any coronary lesion(s); (b) complex coronary lesions.

Fig. 2.

Risk ratios for major adverse cardiovascular events in patients aged ≥65 years undergoing intravascular imaging-guided percutaneous coronary intervention vs. angiography alone, stratified by intravascular imaging modality. IVUS, intravascular ultrasound; OCT, optical coherence tomography.

Fig. 3.

Risk ratios for major adverse cardiovascular events in older patients undergoing intravascular imaging-guided percutaneous coronary intervention vs. angiography alone, stratified by age group.

Fig. 4.

Comparison of MACE between patients aged ≥65 years and those aged <65 years who underwent intravascular imaging-guided PCI. MACE, major adverse cardiovascular events; PCI, percutaneous coronary intervention.

Heterogeneity and sensitivity analysis

Overall heterogeneity was low across all studied outcomes; therefore, a leave-one-out sensitivity analysis was not conducted. Intravascular imaging was associated with lower composite cardiovascular events among studies that reported MACE as TVF (RR 0.66, 95% CI 0.50–0.87; P = 0.004; I² = 39%; Fig. 5) and those that reported MACE as TLF (RR 0.64, 95% CI 0.47–0.87; P = 0.004; I² = 0%; Fig. 5) compared with angiography alone.

Fig. 5.

Sensitivity analysis based on MACE definitions used across included studies. MACE, major adverse cardiovascular events.

The risk of bias in the included trials was assessed using the Cochrane Collaboration tool and was determined to be low (Supplementary Fig. 2, Supplemental digital content 1, https://links.lww.com/MCA/A779). Funnel plot analysis showed no indication of publication bias (Supplementary Fig. 3, Supplemental digital content 1, https://links.lww.com/MCA/A779). The overall certainty of evidence was rated using the GRADE framework and deemed moderate to low for most outcomes (Supplementary Table 2, Supplemental digital content 1, https://links.lww.com/MCA/A779).

Discussion

This meta-analysis of 7164 patients demonstrated a clear benefit of using intravascular imaging to guide PCI in older adults with acute or chronic coronary syndrome as compared to angiography alone. Intravascular imaging, especially IVUS, reduced MACE in older adults, with benefits extending to those with complex coronary lesions. OCT was associated with a numerically lower incidence of MACE compared to angiography alone, though the reduction did not reach statistical significance. These findings support the utility of intravascular imaging in older adults to optimize lesion preparation and stent placement, thereby minimizing cardiovascular complications in this high-risk, historically understudied population.

Although prior meta-analyses have shown improved outcomes with intravascular imaging to guide PCI [6,7], they focused on the general population without reporting outcomes specifically for older adults. Tan et al. [33] performed the first and only RCT to focus on the older population. This trial, which involved 123 older adults aged over 70 years with left main coronary artery lesions, demonstrated a significant reduction in MACE with IVUS guidance compared to angiography alone (13.1% vs. 27.4%; P = 0.031) [33]. Real-world data from Elzeneini et al. [35] using the Nationwide Readmissions Database from 2018 to 2019 found that intravascular imaging was used less frequently to guide PCI in older adults aged ≥75 years compared with those <75 years (6.8% vs. 7.8%; P < 0.001). Similarly, intravascular imaging was used in only 13.1% of the invasive arm of the SENIOR-RITA trial, which found no significant difference in cardiovascular death or nonfatal MI between invasive and conservative strategies in patients aged over 75 years presenting with non-ST-segment elevation myocardial infarction [36]. Notably, the low use of intravascular imaging in the SENIOR-RITA trial may have potentially contributed to the lack of observed benefit with an invasive strategy [36]. Barriers to utilization of intravascular imaging have been attributed to operator training and familiarity, limited availability of imaging consoles in some catheterization laboratories, procedural time constraints, and reimbursement challenges in certain healthcare systems [4,37]. Frailty and multimorbidity, common in older adults, may limit tolerance of longer or more complex procedures, discouraging operators from routine intravascular imaging use. Our findings suggest that intravascular imaging confers cardiovascular benefits in guiding PCI in the older population and highlight the need for further studies identifying potential barriers to intravascular imaging use.

Our subgroup analysis revealed a significant interaction by imaging modality (P = 0.04), with IVUS demonstrating a clear reduction in MACE and OCT showing only a nonsignificant trend. Several factors may explain this difference. First, the largest OCT trial, ILUMIEN IV, reported no difference in TVF using OCT guidance despite achieving greater stent expansion in the OCT arm [29]. This outcome may have been influenced by the level of lesion complexity and patient population in ILUMIEN IV, where the inclusion of a broader range of cases may have diluted the potential benefits of OCT [29]. Second, contrast-induced AKI (CI-AKI), a significant complication following PCI and has been strongly linked to adverse clinical outcomes [38,39]. The decline in renal function and the presence of additional comorbidities in older adults render this population more susceptible to CI-AKI and the consequent poorer outcomes [40]. The risk of CI-AKI may partially explain the attenuated benefits observed in those who underwent OCT, a modality that typically requires additional contrast administration for blood clearance. In contrast, IVUS allows for ultra-low contrast or even zero-contrast PCI protocols, which may be particularly advantageous in older patients with advanced chronic kidney disease [41]. Lastly, the overall sample size in the OCT subgroup was smaller than in IVUS studies, reducing statistical power to detect significant differences despite numerically lower adverse event rates in the OCT arm.

Older patients exhibit more severe, complex, and calcified lesions in the coronary arteries compared with younger patients, and they also tend to have a higher prevalence of comorbidities [42]. These are important factors to consider when evaluating older adults for PCI, as the ability to optimize stent implantation using intravascular imaging in this vulnerable population may carry heightened importance. The need for blood clearance during OCT runs can increase procedure duration and complexity. Furthermore, OCT devices and interpretation require operator expertise and remain less widely adopted than IVUS in many catheterization laboratories [37]. The deeper tissue penetration of IVUS makes it particularly well suited for large vessels, left main disease, heavily calcified lesions, ostial lesions where blood clearance is not feasible, and chronic total occlusion lesions where contrast injection is contraindicated [43]. The less technical nature of IVUS and its potential to minimize contrast exposure while achieving optimal lesion preparation and stent deployment make IVUS an attractive choice for guiding PCI in older adults.

Strengths and limitations

Our study is strengthened by having a large sample size while focusing on older adults, which enabled us to address an important gap in the cardiology literature. By including only RCTs, the findings from our study are less affected by known and unknown confounders. Despite these strengths, our study is limited by the heterogeneity in MACE definitions used across included studies. This heterogeneity may have contributed to some variability in reported outcomes. To address this, we used random effects models to account for study-level variability. Our sensitivity analyses using harmonized definitions (TVF vs. TLF) and individual components demonstrated consistent reductions in adverse outcomes with intravascular imaging guidance. The majority of included studies reported outcomes for patients aged 65 years and older, with only one study reporting outcomes for patients 75 years and older. This limited our ability to perform subgroup analysis for patients 75 years and older and could further limit the direct applicability of our study findings to this specific age group. Although IVUS-guided PCI demonstrated clear benefits in older adults, fewer studies utilized OCT guidance, leaving its role less well-defined. Finally, our meta-analysis was conducted at the study level rather than the patient level and mostly utilized subgroup data of larger RCTs, which limited our ability to integrate study outcomes and to further explore the drivers of MACE. Further research is needed to explore the drivers of MACE reduction with intravascular imaging, as well as the interaction between age, lesion complexity, and intravascular imaging modality to better refine PCI imaging strategies in this demographic.

Conclusion

This meta-analysis provides strong evidence to support the use of intravascular imaging in older adults undergoing PCI. Intravascular imaging guidance, particularly with IVUS, significantly reduces MACE in older patients compared with angiography alone. These findings support the adoption of intravascular imaging, particularly IVUS guidance, as the standard practice in PCI for older adults, including those with complex coronary lesions. Further research is needed to define barriers to the use of intravascular imaging in older adults and to address remaining uncertainties regarding the oldest-old population, lesion complexity, patient-specific outcomes, and the role of OCT guidance in this population.

Supplementary Material

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