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

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 patients 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.

Society for Cardiovascular Magnetic Resonance perspective on the 2021 AHA/ACC Chest Pain Guidelines

“…Additionally, the recent FORECAST (Fractional Flow Reserve Derived From Computed Tomography Coronary Angiography in the Assessment and Management of Stable Chest Pain) trial of over 1400 patients, while referral to invasive angiography was lower, the use of FFR-CT did not demonstrate any benefits in terms of healthcare costs, cardiovascular outcomes, or quality of life compared to CT-alone [ 10 ]. Similarly, the recent RAPID-CT (Rapid Assessment of Potential Ischaemic Heart Disease with CTCA) trial [ 11 ] included 1748 patients with intermediate risk with suspected or a provisional diagnosis of acute coronary syndrome randomised to Early CCTA and standard of care compared with standard of care only. The study demonstrated that early CCTA did not alter overall coronary therapeutic interventions or one-year clinical outcomes.…”

Prognostic Value of Coronary CT Angiography-Derived Fractional Flow Reserve in Non-obstructive Coronary Artery Disease: A Prospective Multicenter Observational Study

“…In addition to the unique ability for non-invasive qualitative and quantitative evaluation of coronary atherosclerotic plaque, CCTA can provide functional information without the increased burden of radiation exposure and administration of stress agents. Compared with conventional CCTA alone, it has been demonstrated that CT-FFR had improved discrimination of ischemia (33) the 9-month costs of patients with stable angina in the CT-FFR group were slightly higher than that in the routine care group, but the difference was not significant (p = 0.10) (34).…”

Detection of Vulnerable Coronary Plaques Using Invasive and Non-Invasive Imaging Modalities

“…Moreover, in a sub-study of the PROSPECT trial, a A novel CT feature is the measurement of fractional flow reserve. This provides additional information on the hemodynamic effects of coronary plaques and is able to reduce the need for invasive coronary angiography after CTCA [117]. The role of fractional flow reserve for the detection of vulnerable plaques seems questionable, since most ACS arises from non-significant coronary plaques.…”