Fractional flow reserve derived from computed tomography coronary angiography in the assessment and management of stable chest pain: the FORECAST randomized trial

Author:

Curzen Nick12ORCID,Nicholas Zoe2,Stuart Beth3ORCID,Wilding Sam3ORCID,Hill Kayleigh3ORCID,Shambrook James4ORCID,Eminton Zina3,Ball Darran3ORCID,Barrett Camilla3ORCID,Johnson Lucy3,Nuttall Jacqui3ORCID,Fox Kim5,Connolly Derek6,O’Kane Peter7ORCID,Hobson Alex8ORCID,Chauhan Anoop9ORCID,Uren Neal10,Mccann Gerry11,Berry Colin12ORCID,Carter Justin13,Roobottom Carl14ORCID,Mamas Mamas15ORCID,Rajani Ronak16,Ford Ian17ORCID,Douglas Pamela18ORCID,Hlatky Mark19ORCID

Affiliation:

1. Faculty of Medicine, University of Southampton

2. Coronary Research Group, University Hospital Southampton

3. Clinical Trials Unit, University of Southampton

4. Cardiothoracic Radiology, University Hospital Southampton

5. Imperial College, London, UK

6. Sandwell Hospital, Birmingham, UK

7. Dorset Heart Centre, University Hospitals Dorset, Bournemouth

8. Queen Alexandra Hospital, Portsmouth

9. Royal Victoria Hospital, Blackpool

10. Royal Infirmary, Edinburgh

11. Department of Cardiovascular Sciences, University of Leicester & NIHR Biomedical Research Centre, Glenfield Hospital, Leicester, UK

12. British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow

13. University Hospital of North Tees, Stockton on Tees

14. Derriford Hospital, Plymouth

15. Royal Stoke University Hospital, Stoke-on-Trent

16. Guy’s & St Thomas’ Hospital, London

17. Robertson Centre for Biostatistics, University of Glasgow, Glasgow

18. Duke University, Durham, NC, USA

19. Stanford University, Stanford, CA, USA

Abstract

Abstract Aims  Fractional flow reserve (FFRCT) using computed tomography coronary angiography (CTCA) determines both the presence of coronary artery disease and vessel-specific ischaemia. We tested whether an evaluation strategy based on FFRCT would improve economic and clinical outcomes compared with standard care. Methods and results  Overall, 1400 patients with stable chest pain in 11 centres were randomized to initial testing with CTCA with selective FFRCT (experimental group) or standard clinical care pathways (standard group). The primary endpoint was total cardiac costs at 9 months. Secondary endpoints were angina status, quality of life, major adverse cardiac and cerebrovascular events, and use of invasive coronary angiography. Randomized groups were similar at baseline. Most patients had an initial CTCA: 439 (63%) in the standard group vs. 674 (96%) in the experimental group, 254 of whom (38%) underwent FFRCT. Mean total cardiac costs were higher by £114 (+8%) in the experimental group, with a 95% confidence interval from −£112 (−8%) to +£337 (+23%), though the difference was not significant (P = 0.10). Major adverse cardiac and cerebrovascular events did not differ significantly (10.2% in the experimental group vs. 10.6% in the standard group) and angina and quality of life improved to a similar degree over follow-up in both randomized groups. Invasive angiography was reduced significantly in the experimental group (19% vs. 25%, P = 0.01). Conclusion  A strategy of CTCA with selective FFRCT in patients with stable angina did not differ significantly from standard clinical care pathways in cost or clinical outcomes, but did reduce the use of invasive coronary angiography.

Funder

Research & Development Department of University Hospital Southampton NHS Foundation Trust

NIHR Research Professorship

IHR Leicester Biomedical Research Centre

NIHR Leicester Clinical Research Facility

Publisher

Oxford University Press (OUP)

Subject

Cardiology and Cardiovascular Medicine

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