Optical Coherence Tomography Morphologic and Fractional Flow Reserve Assessment in Diabetes Mellitus Patients

Study Overview
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Brief Summary
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Title: Combined Optical Coherence Tomography Morphologic and Fractional Flow Reserve Hemodynamic Assessment of Non-Culprit Lesions to Better Predict Adverse Event Outcomes in Diabetes Mellitus Patients COMBINE (OCT-FFR) Prospective Register To study the natural evolution of patients with at least one intermediate angiographic but non-hemodynamic significant stenotic lesion, in two subgroups of patients, with TCFA vs. no TCFA as detected by OCT imaging and to compare these two groups of patients with each other as well as to a subset of patients with FFR-positive and PCI-treated intermediate lesions on future MACE.

Detailed Description
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Hypothesis Diabetes Mellitus (DM) patients with angiographically intermediate coronary lesions remain at risk for future MACE events, including those patients with fractional flow reserve (FFR) negative lesions. Use of FFR measurements combined with Optimal Coherence Tomography (OCT) detection of thin-cap fibroatheroma (TCFA) in will help predict future MACE rates. Objective To study the natural evolution of patients with at least one intermediate angiographic but non-hemodynamic significant stenotic lesion, in two subgroups of patients, with TCFA vs. no TCFA as detected by OCT imaging and to compare these two groups of patients with each other as well as to a subset of patients with FFR-positive and PCI-treated intermediate lesions on future MACE. Design Prospective, open label natural history registry. DM patients bearing target lesions {Any de novo lesion with an angiographic visual estimation of ≥ 40%- ≤ 80% Diameter Stenosis (DS) that is located in a non-grafted coronary segment. In patients with an MI at presentation the target lesion should be different from the culprit lesion} and have undergone FFR and OCT imaging as for clinical routine will be prospectively enrolled and followed. Patients with negative FFR (> 0.80) will be divided in two categories depending on corelab OCT imaging findings: No-TCFA (cap thickness >65µ) (Group A) or TCFA (cap thickness ≤ 65µ) (group B). All patients that had a positive FFR and therefore have been treated with PCI as per standard care in all target lesions will also be followed (group C), however if after the PCI there is at least one remaining target lesion where FFR was negative these patients should be followed in group A or B depending on the OCT findings. Clinical endpoints at 1.5 year will be recorded. The investigators strongly recommend that all major epicardial coronary vessels of stentable size that show any form of atherosclerosis to be interrogated with FFR and OCT. The investigators strongly recommend to not perform cap thickness measurements in the cathlab. The plaque cap thickness as measured in the corelab will not be disclosed to operators and patients. Population Patients aged ≥18 years Diabetes mellitus (DM) patients with any presentation. Coronary angiography, FFR and OCT imaging in at least one coronary de novo stenosis in a native vessel with a visually estimated diameter of stenosis (DS) of ≥ 40%-≤ 80% (target lesion). Angiographic criteria target lesion: (i) ≥ 40%-≤ 80% diameter stenosis (DS) (ii) de novo lesion located in native non-grafted vessel (iii) target lesion reference diameter of ≥ 2.0 mm (iv) TIMI 3 flow Primary Endpoint The per patient incidence of the target lesion(s) related composite MACE defined as Cardiac Death, MI, clinically-driven target lesion revascularisation or hospitalization due to unstable or progressive angina at 18 months in the FFR-negative No-TCFA (Group A) and FFR-negative TCFA (Group B). Statistics This is an observational study (prospective natural history register) where no randomization takes place, therefore a power calculation is strictly not necessary. However, in order to observe meaningful differences between groups (as described in the design) and deduct founded conclusions, the minimal number of patients required was calculated as follows. The target lesion related primary endpoint at 18 months in the A and B group respectively are assumed to be 5 % and 20% respectively. Taking into account an expected loss in FU of 7%, a total of 500 patients enrolled in the study will provide 80% power to reject the null hypothesis with 5% type I error (alpha). The enrolment in group C will stop after the first 166 patients have been enrolled in this group. The rest of the rest of 334 patients will be distributed in groups A and B depending on the OCT corelab findings. Nul hypothesis: the MACE rate in group B is not different from group A.

Official Title
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Combined Optical Coherence Tomography Morphologic and Fractional Flow Reserve Hemodynamic Assessment of Non-Culprit Lesions to Better Predict Adverse Event Outcomes in Diabetes Mellitus Patients. COMBINE (OCT-FFR) Prospective Register

Conditions
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Diabetes Mellitus, Coronary Artery Disease, Coronary Atheroscleroses

Intervention / Treatment
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* Procedure: Optical Coherence Tomography


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Age ≥ 18 years History of DM with any indication for angiography (Stable Angina (SA) or any type of Acute Coronary Syndrome (ACS) including ST-Elevation MI). Coronary angiography, including FFR and OCT imaging of at least one coronary de novo stenosis in a native not-grafted vessel with a visually estimated diameter stenosis (DS) of ≥ 40 - ≤ 80% (target lesion) . Target lesion should be other than the culprit lesion(s) in patients presenting with MI (STEMI or non-STEMI). Exclusion Criteria: TIMI flow < 3 in the target lesion(s) Target lesion reference diameter (on visual estimation) < 2.0 mm Known left ventricular ejection fraction <30% Known malignancy Life expectancy < 2 years Unwilling or unable to provide inform consent

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Group A<br>Patients with negative FFR (> 0.80) in the target lesion & decided on OCT (Optical Coherence Tomography) imaging findings with NO thin-cap fibroatheroma | Procedure: Optical Coherence Tomography<br>* Patients aged ≥ 18 years bearing target lesions that fulfil the inclusion criteria and have undergone FFR and OCT imaging as per clinical practice will be enrolled in the study.<br>* Other names: OCT;|
| Group B<br>Patients with negative FFR (> 0.80) in the target lesion & decided on OCT (Optical Coherence Tomography) imaging findings presence of ≥ thin-cap fibroatheroma | Procedure: Optical Coherence Tomography<br>* Patients aged ≥ 18 years bearing target lesions that fulfil the inclusion criteria and have undergone FFR and OCT imaging as per clinical practice will be enrolled in the study.<br>* Other names: OCT;|
| Group C<br>Patients hosting FFR-positive target lesions that have been treated with PCI as per standard care and have further no TCFA lesions. | Procedure: Optical Coherence Tomography<br>* Patients aged ≥ 18 years bearing target lesions that fulfil the inclusion criteria and have undergone FFR and OCT imaging as per clinical practice will be enrolled in the study.<br>* Other names: OCT;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| The per patient incidence of the target lesion(s) related composite MACE | The per patient incidence of the target lesion(s) related composite MACE defined as Cardiac Death, MI, clinically-driven target lesion revascularisation or hospitalization due to unstable or progressive angina at 18 months in the FFR-negative No-TCFA (Group A) and FFR-negative TCFA (Group B). | 18 months after procedure | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| The per patient incidence of the target lesion(s) related composite MACE: | Cardicac death, MI, clinically- driven revascularization or hospitalization due to unstable or progressive angina between FFR-negative TCFA (Group B) and the group of patients with PCI-treated FFR-positive lesions (Group C). | 18 months after procedure | 
| The per patient incidence composite MACE | The per patient incidence composite MACE: Cardiac death, MI, any clinically driven-revascularization or hospitalization due to unstable or progressive angina between FFR-negative TCFA (Group B) and the group of patients with PCI treated FFR positive lesions (Group C). | 18 months after procedure | 
| The incidence of MACE (Cardiac death, MI, any clinically driven-revascularization or hospitalization due to unstable or progressive angina) | deriving from non PCI treated lesions between TCFA hosting patients anywhere in the major coronary of stentable size vs. patients with no TCFA (this analysis will be run in the total pool of patients after treatment of all FFR positive lesions and does not take in account the angiographic severity of the lesions ie. the location of the TCFA can be elsewhere than the target lesion ) | 18 months after procedure | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Diabetes Mellitus, Thincap fibroatheroma, Optical Coherence Tomography, Fractional Flow Reserve