Fractional flow reserve derived from computed tomography coronary angiography in the assessment and management of stable chest pain: the FORECAST randomized trial
Nick CurzenZoe NicholasBeth StuartSam WildingKayleigh HillJames ShambrookZina EmintonDarran BallMillie BarrettLucy JohnsonJacqui NuttallKim FoxDerek ConnollyP. O’KaneAlex HobsonAnoop ChauhanNeal UrenGerry P McCannColin BerryJustin CarterCarl RoobottomMamas A. MamasRonak RajaniIan FordPamela S. DouglasMark A. Hlatky
Key result
CTCA with selective FFRCT yields similar costs to standard care but cuts invasive angiography ~24%.
- Difference +£−114
- 95% CI -£112 to +£337
- P=0.10
- n=1,400
Figures
Why the study?
It was unknown whether an evaluation strategy using CTCA with selective FFRCT would improve economic and clinical outcomes compared with standard care.
Does an evaluation strategy based on initial CTCA with selective FFRCT reduce total cardiac costs at 9 months in patients with stable chest pain compared to standard clinical care?
Key Points
- This trial aimed to assess whether a strategy based on FFRCT improves clinical and economic outcomes compared with standard care in patients with stable chest pain.
- Randomized trial involving 1400 patients across 11 centers, comparing selective FFRCT with standard clinical care.
- Primary endpoint was total cardiac costs at 9 months; secondary endpoints included angina status and quality of life.
- In the experimental group, 96% underwent CTCA, and 38% subsequently had FFRCT.
- Total cardiac costs were higher in the experimental group by £114 (+8%) but not significantly (P=0.10).
- Major adverse cardiac events were similar in both groups (10.2% vs. 10.6%).
- Invasive angiography usage was significantly lower in the experimental group (19% vs. 25%, P=0.01).
Study Design
Type
RCT (n=1,400)
Multicenter
Yes
Structured PICO
Does an evaluation strategy based on initial CTCA with selective FFRCT reduce total cardiac costs at 9 months in patients with stable chest pain compared to standard clinical care?
P
Population
1400 patients with stable chest pain across 11 centres
I
Intervention
Initial testing with computed tomography coronary angiography (CTCA) with selective fractional flow reserve (FFRCT)
C
Comparator
Standard clinical care pathways
O
Outcome
Total cardiac costs at 9 months
Main Result
Effect estimate: Difference +£114 (95% CI -£112 to +£337)
p-value: p=0.10
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Results from FORECAST indicate that CTCA and FFRCT as a frontline strategy may not be associated with the financial savings projected from observational data by NICE. However, the reduction in invasive coronary angiography is important and will be very attractive to patients. More data is needed to determine the optimal use for FFRCT in clinical practice.”
“The real question, based on the observational data, wasn't so much would it reduce angiography rates without increasing rates of clinical events or coronary revascularization, because these things have been consistent in the observational studies. It was more whether the strategy of FFRCT was cost-effective in these patients.”
“FFRCT uses the output from a computed tomography (CT) scan of the coronary arteries. This tells us whether there are narrowings or blockages in the coronary arteries, and then incorporates this into a sophisticated model to reveal whether the narrowings are causing a restriction in the blood supply to the heart. By knowing both whether there are narrowings and also whether there is a restriction in blood supply, doctors can decide whether a patient is experiencing angina and then the best way of treating them. FFRCT may save many patients from the inconvenience and risk of an invasive angiogram plus provide cost savings to the NHS.”
Implication
A strategy of CTCA with selective FFRCT in patients with stable chest pain does not significantly change total cardiac costs or clinical outcomes at 9 months, but it significantly reduces the need for invasive coronary angiography.
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.
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Cite This Study
Curzen et al. (2021) conducted an RCT in stable chest pain (n=1,400). CTCA with selective FFRCT vs. standard clinical care pathways was evaluated on total cardiac costs at 9 months (Difference +£114, 95% CI -£112 to +£337, p=0.10). CTCA with selective FFRCT did not significantly differ from standard care in 9-month cardiac costs (difference +£114; P=0.10) but reduced invasive coronary angiography (19% vs 25%; P=0.01).