Comparative effectiveness and outcomes of physiology- and imaging-guided PCI: an evidence synthesis and network meta-analysis of FFR, iFR, OCT, and IVUS

Background Multiple coronary guidance strategies including angiography, physiology-based assessment, and intracoronary imaging are used to optimize percutaneous coronary intervention, yet their comparative effectiveness across clinical outcomes remains uncertain. Methods A comprehensive network meta-analysis incorporated fifty randomized studies evaluating angiography, FFR, iFR, IVUS, and OCT. The primary outcome was major adverse cardiovascular events (MACE). Secondary outcomes included all-cause mortality, cardiac death, myocardial infarction, stent thrombosis, target lesion revascularization, and target vessel revascularization. Random effects models were applied and interventions were ranked using SUCRA. Results A total of 50 studies involving 39,863 patients were included, of whom 29,571 were male and 10,031 were female. Across guidance modalities, 15,463 patients underwent angiography-guided PCI, 10,728 IVUS-guided, 6,001 FFR-guided, 3,512 iFR-guided, and 3,849 OCT-guided PCI. In the network meta-analysis, intravascular imaging strategies demonstrated favorable outcomes across evaluated endpoints. Compared with IVUS, angiography-guided PCI was associated with higher rates of major adverse cardiovascular events (RR 1.28, 95% CI 1.13–1.46), all-cause mortality (RR 1.30, 95% CI 0.98–1.63), myocardial infarction (RR 1.73, 95% CI 1.28–2.40), target lesion failure (RR 1.50, 95% CI 1.19–1.93), and stent thrombosis (RR 1.80, 95% CI 1.25–2.70). Physiology-guided PCI using iFR was associated with higher risk estimates for all-cause mortality (RR 1.72, 95% CI 1.06–2.79) and cardiac death (RR 2.21, 95% CI 1.24–4.24) compared with IVUS. OCT demonstrated outcomes comparable to IVUS, with no statistically significant differences in major adverse cardiovascular events (RR 1.00, 95% CI 0.80–1.28) or cardiac death (RR 0.86, 95% CI 0.47–1.59). Sensitivity analyses yielded similar estimates. Overall, probabilistic ranking analyses favored intravascular imaging strategies, although effect estimates among non-angiographic modalities overlapped. Conclusions Advanced PCI guidance strategies using intravascular imaging or invasive physiological assessment are associated with improved clinical outcomes compared with angiography alone. However, no single non-angiographic modality demonstrates definitive superiority, supporting individualized selection of guidance strategies based on clinical and procedural context. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/view/CRD420251238909 , identifier CRD420251238909.