FFR-CT Guidance for Stable Angina Holds Up Longer Term

Longer-term registry data support CT-derived fractional flow reserve (FFRCT) as a non-invasive gatekeeper to invasive approaches for stable angina, researchers found from the ADVANCE FFRCT registry.

Abnormal values ≤0.80 were associated with more revascularizations (38.4% vs 5.6%, RR 6.87, 95% CI 5.59-8.45) and cardiovascular deaths or MIs (0.8% vs 0.2%, RR 4.22, 95% CI 1.28-13.95) within a year, according to researchers led by Manesh Patel, MD, of the Duke Clinical Research Institute in Durham, North Carolina.

The low-FFRCT group also had a nonsignificant trend for more major adverse cardiac events (MACE; 1.5% vs 0.19%, RR 1.81, 95% CI 0.96-3.43), the researchers added in their report published online in JACC: Cardiovascular Imaging.

Of patients recommended for medical therapy alone after FFRCT, 92.9% remained on these medications without revascularization or MACE at 1 year.

"These data together with the broader outcomes data indicate the safety of patient management following the incorporation of FFRCT into a decision pathway and in most patients with a negative FFRCT, the avoidance of invasive evaluation," the researchers wrote.

Also,"the incorporation of FFRCT may mitigate the high reported rates of ICA [invasive coronary angiography] following the detection of moderate atherosclerosis by [coronary CT angiography]," they added.

The new data from Patel's group certainly helps answer questions regarding the impact of FFRCT on patients more typical of daily coronary CT angiography practice, Todd Villines, MD, of Walter Reed National Military Medical Center in Bethesda, Maryland, wrote in an accompanying editorial.

At the same time, however, he cautioned about several important limitations that should temper enthusiasm.

An earlier 90-day report from the ADVANCE registry showed treatment recommendations from the core lab were changed in 66.9% of cases when FFRCT was added to coronary CT angiography results.

Yet, this included more than 10% of subjects getting redirected to revascularization (primarily percutaneous coronary intervention), which raises concerns about induced revascularizations, costs, and clinical outcomes when FFRCT is broadly applied in a lower-risk population, according to Villines.

FFRCT currently costs $1,450 per Medicare patient, and the coronary CT angiography it is based on can have rejection rates exceeding 20% due to image artifacts that prohibit its accurate performance, the editorialist added.

The ADVANCE FFRCT registry totaled more than 5,000 patients with documented atherosclerosis of at least 30% on coronary CT angiography.

All were offered an initial treatment strategy based on the results of coronary CT angiography alone, which included the recommendation of physiological assessment with FFRCT for stenosis in the 30% to 90% range. Once the FFRCT result was available (from analysis by HeartFlow, the proprietor of the FFRCT technology), site investigators reported a treatment strategy taking into account the coronary CT angiography and the FFRCT.

The observational nature of the registry analysis was its major limitation. The ongoing FORECAST and PRECISE trials will be important because they test how a CT angiography-FFRCT strategy informs practice and affects clinical outcomes and costs, the authors suggested.

"Among non-invasive tests, the ability of coronary [CT angiography] to accurately identify, quantify, and characterize whole-heart coronary atherosclerosis to refine an individuals' cardiovascular risk and the intensity of preventive therapies is unparalleled," Villines wrote.

Upcoming chest pain guidelines from the American College of Cardiology and the American Heart Association are expected to give coronary CT angiography a class I indication for the evaluation of patients with suspected coronary artery disease, he noted.

The ADVANCE registry was funded by HeartFlow.

Patel reported research grants from HeartFlow, Bayer, Janssen, the NHLBI; and serving on the advisory boards of HeartFlow, Bayer, and Janssen.

Villines disclosed no financial conflicts of interest.

The FFR CT ripcord Study - jacc: Cardiovascular Imaging

Because the safety tadalafil india 13 and effectiveness. Secondary endpoints were: 1) correlation between vessels labeled as significant on the basis of interpretation of the CT angiogram alone versus interpretation with ffrct data available; and 2) comparison between individual coronary arteries labeled as targets for revascularization. Jude Medical, and Haemonetics; and travel sponsorships from Biosensors, Lilly/D-S, and Abbott Vascular. Thus, the availability of FFR data resulted in an overall change in the decision for treatment (combining change in management category plus change in PCI target vessel) in 44 of the study population compared to CTA alone. The ideal screening test for patients presenting for the first time with chest pain would describe both coronary anatomy and the presence of ischemia and would be readily accessible, low cost, and noninvasive. Treatment for...

Therefore, the physiological data were systematically available as part of the evaluation of all management options (OMT and revascularization in contrast to the trials in which FFR was used in patients already committed to PCI. The guideline recommends offering non-invasive functional imaging for myocardial ischaemia if 64slice (or above) ccta has shown coronary artery disease of uncertain functional significance, cialis dosages available size or is non-diagnostic. This finding highlights the potential limitation biaxin 1000 mg bid of anatomy-based screening in patients with symptoms thought to be due to myocardial ischemia. Although the nice guideline on chest pain does not consider FFR, other guidelines (such as those of the European Society of Cardiology and American College of Cardiology) state that lesions with an FFR.80 or less are functionally significant and revascularisation may be considered. The secondary aim was to assess whether the findings from the original invasive ripcord study could be reproduced using noninvasive angiography and ffrct. This was the same sample size evaluated in the ripcord study.