Comparison of Computed Tomogram Coronary Angiography (CTCA) alone versus CTCA with selective FFRCT in patients presenting with stable chest pain: a FORECAST trial substudy

Aims The original FORECAST trial was designed to compare a strategy of CTCA and selective FFRCT to standard care in patients attending Rapid Access Chest Pain clinics in UK centres. This is a prespecified analysis of the FORECAST trial to compare outcomes between the patients in the experimental arm (CTCA + selective FFRCT) and patients in the reference arm who underwent CTCA alone as their initial test of choice. Methods and results The FORECAST trial recruited 1400 patients randomised between 2 strategies: (i) initial test of choice at the discretion of the healthcare provider (standard care arm) or (ii) CTCA +/- FFRCT. Prior to randomization, clinicians stated their preference for choice of the first test if the patient were to be randomized to standard care. 459 patients (66%) in the standard care pathway were selected for CTCA as the first test of choice. Similarly, 453 (65%) of the patients who were subsequently randomised into the experimental arm were selected for CTCA as initial test prior to that randomisation. This comparison is an intention-to-test (ITT) analysis comparing the post randomisation outcomes of the population of patients who were selected for CTCA as the test of first choice prior to randomisation (labeled as the CTCA stratum). The following comparisons were made: (i) primary trial outcomes at 9 months including (a) total cardiac costs, (b) use of other tests, (c) clinical events & (d) time to final management plan; (ii) a comparison between the CTCA stratum groups and the remainder of the standard care arm (i.e. patients randomised to standard care who were selected for an initial test other than CTCA). Of the CTCA stratum patients, there was no significant difference between randomised groups in the median total cardiac costs at 9 months (£594 (IQR 570–1,127) in the experimental arm vs £594 (574– 966) in the usual care arm (P=0.325)). The number of additional non-invasive tests was significantly lower in the experimental group than in the standard care CTCA patients (43 patients (8.9%) vs 72 (16%), (P=0.005)). Time to final management plan was also significantly lower in the experimental arm (median 64 days (IQR 48-110) versus 75 days (55-126) (P<0.001)). There was no significant difference in the rate of adverse cardiac events. Patients randomised to standard care who were not in the CTCA stratum had significantly higher median total cardiac costs when compared to either of the CTCA stratum groups, with median total cardiac costs of £908 (IQR 592–1,161) vs £594 (570-1,123) vs £594 (570-966), respectively (P<0.001). Conclusion In this prespecified FORECAST substudy of patients whose clinicians preferred CTCA as the first test prior to randomisation, the CTCA +/- FFRCT strategy, when compared to CTCA alone, was cost neutral in the UK, and associated with significantly fewer additional noninvasive tests. Time to final management plan was also significantly lower in the experimental arm (median 64 days (IQR 48-110) versus 75 days (55-126) in the standard care CCTA arm (P<0.001)).