Objective <p>This study aimed to evaluate the cost-effectiveness of Optical Coherence Tomography (OCT)-guided versus coronary angiography-guided Percutaneous Coronary Intervention (PCI) within the Chinese healthcare system, exploring its economic value for patients with complex coronary artery lesions.</p> Methods <p>A Markov model simulated a cohort of 10,000 patients aged 65 with coronary heart disease over a lifetime horizon (20 years). Adopting a healthcare system perspective, the study compared OCT-guided versus angiography-guided PCI strategies. Model parameters integrated 2-year follow-up data from the OCCUPI trial, clinical parameters from a meta-analysis of 6 RCTs, the Chinese National Reimbursement Drug List (2025), and health utility values for the Chinese population. A 5% discount rate was applied for the cost-utility analysis. The primary outcome was the Incremental Cost-Effectiveness Ratio (ICER).</p> Results <p>This study compared the cost-effectiveness of OCT-guided versus angiography guided PCI over short-term (within-trial) and long-term (20 years) horizons. In the short term (1 year), the ICER for OCT versus angiography was substantially high at 2,154,501.65 CNY/QALY, indicating a lack of cost-effectiveness advantage. However, in the lifetime simulation, OCT demonstrated significant cost-effectiveness. When using transition probabilities from the OCCUPI trial, the ICER markedly decreased to 6,815.47 CNY/QALY, indicating strong cost-effectiveness. When using transition probabilities from the meta-analysis incorporating multiple studies, the ICER was 42,374.86 CNY/QALY, below the willingness-to-pay threshold of one times China’s per capita GDP (99,665 CNY), also demonstrating cost-effectiveness. Subgroup analyses revealed that the economic advantage of OCT was more pronounced in patients with diabetes, unprotected left main disease, small vessel disease, and multivessel disease. Sensitivity analyses confirmed the robustness of these findings. The results indicate that OCT-guided PCI exhibits a typical “high initial investment, long-term significant benefit” profile, representing a cost-effective interventional strategy over a lifetime horizon.</p> Conclusion <p>Within the Chinese healthcare system, OCT-guided PCI demonstrates favorable cost-effectiveness for patients with complex coronary artery lesions. Its higher initial costs are offset by long-term health gains, supporting its value for broader adoption.</p>