Optical coherence tomography-guided stent optimization and clinical outcomes in all-comer patients with ST-elevation myocardial infarction

AIMS: Although the advantages of intra-coronary imaging guidance in percutaneous coronary intervention (PCI) have been reported, the advantage of optical coherence tomography (OCT) guided PCI has not been elucidated in patients with ST-elevation myocardial infarction (STEMI). This study assessed the association between OCT findings after stent implantation and 1-year outcomes in an all-comer STEMI population. METHODS AND RESULTS: The ATLAS-OCT trial was a prospective, multicentre, single-arm study enrolling STEMI patients within 24 h of symptom onset. OCT-guided PCI was preferred when feasible. This analysis included patients with analysable post-PCI OCT images. The primary endpoint was target vessel failure (TVF; all-cause death, target vessel myocardial infarction [TVMI], or target vessel revascularization [TVR]). OCT images were analysed independently, and outcomes assessed at 12 months. Of 632 patients, 439 (69.5%) underwent OCT-guided stenting with final analysable imaging. Mean minimal stent area (MSA) and stent expansion (SE) were 6.21 ± 2.27 mm² and 76.8 ± 15.6%, respectively. Optimization criteria (MSA > 4.5 mm² and/or SE > 70%) were met in 87.7%. Suboptimal expansion was associated with higher TVF (20.4% vs. 8.1%; HR 2.57, 95% CI: 1.29-5.11), driven by TVMI and TVR. Each 1 mm² MSA decrease and 10% SE reduction increased TVF odds by 23% and 33%, respectively. Minor OCT findings were not significantly associated with outcomes. CONCLUSION: In STEMI, suboptimal MSA and SE determined by OCT were associated with higher adverse event risk. These findings support OCT-guided PCI optimization to improve outcomes and warrant further evaluation in randomized trials. STUDY REGISTRATION: University Hospital Medical Information Network Clinical Trials Registry of Japan (UMIN-CTR number: 000048590).