Clinical trial NCT03976921: Impact of Stress CT Myocardial Perfusion on Downstream Resources and Prognosis
Official title: Impact of Stress Cardiac Computed Tomography Myocardial Perfusion on Downstream Resources and PROgnosis in Patients With Suspected or Known Coronary Artery Disease: a Multicenter International Study
Study type: INTERVENTIONAL
Overall status: UNKNOWN
Phase: NA
Conditions: Coronary Artery Disease
Myocardial Ischemia
Keywords: Computed Tomography Perfusion
Cardiovascular Outcomes
Cost-effectiveness
Lead sponsor: Centro Cardiologico Monzino
Sponsor class: OTHER
Collaborators: name: Medical University of South Carolina
name: Semmelweis University Heart and Vascular Center
name: Emory University
name: UMC Utrecht
name: Johns Hopkins University
name: Policlinico Hospital
First posted: 2019-06-06
Enrollment: 2000
Sex: ALL
Minimum age (years): 18
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: PARALLEL
Intervention model description: Upon completion of the screening procedure and enrollment, the patients will be randomized 1:1 to the CT-based strategy (Group A) or usual care (Group B).
Primary purpose: HEALTH_SERVICES_RESEARCH

Brief summary: CT myocardial perfusion imaging (CTP) represents one of the newly developed CT-based techniques but its cost-effectiveness in the clinical pathway is undefined. The aim of the study is to evaluate the usefulness of combined evaluation of coronary anatomy and myocardial perfusion in intermediate to high-risk patients for suspected CAD or with known disease in terms of clinical decision-making, resource utilization and outcomes in a broad variety of geographic areas and patient subgroups.

Detailed description: The use of cardiac computed tomography angiography (CCTA) is usually suggested in low to intermediate risk for its diagnostic and prognostic role to rule out CAD with low radiation exposure. In the setting of intermediate to high risk patients, the addition of functional information is prognostically useful and, in patients with previous history of percutaneous coronary intervention (PCI), functional strategy has been shown to be more cost-effective as compared to anatomical assessment CT myocardial perfusion imaging (CTP) represents one of the newly developed CT-based techniques, combining both anatomical and functional evaluation of CAD in a single imaging modality. More recently, stress CTP was shown to provide additional diagnostic value as compared to CCTA alone in intermediate to high risk patients. The purpose of this study will be to evaluate the usefulness and impact of combined evaluation of coronary artery anatomy and myocardial perfusion with CCTA+CTP in intermediate to high risk patients for suspected CAD or with known disease in terms of clinical decision-making, resource utilization, and outcomes in a broad variety of geographic areas and patient subgroups.

CTP-PRO study is a cooperative, international, multicentre, prospective, open-label, randomized controlled study evaluating the cost-effectiveness of a CCTA+CTP strategy versus usual care in intermediate to high risk patients with suspected or known CAD who undergo clinically indicated diagnostic evaluation.

Patients will be screened for study eligibility. Patients meeting all selection criteria will be asked to sign an informed consent document prior to undergoing any study-specific evaluation; then a structured interview will be performed and a clinical history obtained, assessing the presence of common cardiac risk factors, drug therapy (focus on statin, aspirin and/or antiplatelet agent use) and symptoms (typical or atypical angina, to estimate the pre-test likelihood of CAD).

Upon completion of the screening procedure and enrollment, the patients will be randomized 1:1 to the CT-based strategy (Group A) or usual care (Group B). Patient follow-up will be performed at 1 year (± 1 month) and 2 years (± 1 month) by trained interviewers who check medical records or by phone interview collecting the following information: downstream testing; overall radiation exposure; outcomes; cost-effectiveness estimation.

The primary endpoint of the study is the reclassification rate of CCTA in group B due to the addition of CTP. The secondary endpoint will be the comparison between group A and group B in terms of non-invasive and invasive downstream testing, prevalence of obstructive CAD at ICA, revascularization, cumulative ED and overall cost during the follow-up at 1- and 2-years. The tertiary endpoint will be the comparison between each group in terms of MACE and cost-effectiveness at 1- and 2-years.

Eligibility criteria: Inclusion Criteria:

* Consecutive patients (age ≥ 18 years) with known or suspected CAD referred for clinically indicated diagnostic evaluation.
* CCTA has to be performed with the state of art in terms of scanner technology as follow: Revolution CT (GE Healthcare, Milwaukee, WI), CardioGraphe (Arineta, Caesarea, Israel), SOMATOM Force (Siemens, Forchheim, Germany), Brilliance iCT and IQon CT (Philips, Best, Netherlands), Aquilion One Vision (Toshiba Medical Systems Corp., Otawara, Japan).

Exclusion Criteria:

* Performance of any non-invasive diagnostic testing within 90 days before enrollment
* Low to intermediate pre-test likelihood of CAD according to the updated Diamond-Forrester risk model score
* Acute coronary syndrome
* Need for an emergent procedure
* Evidence of clinical instability
* Contra-indication to contrast agent administration and/or impaired renal function
* Inability to sustain a breath hold
* Pregnancy
* Cardiac arrhythmias
* Presence of pace maker or implantable cardioverter defibrillator
* Contra-indications to the administration of sub-lingual nitrates, beta-blockade and adenosine
* Structural cardiomyopathy outside of suspected or know ischemic heart disease

Primary outcomes:
measure: Reclassification rate of CCTA in group B due to the addition of CTP
timeFrame: 30 days.
Secondary outcomes:
measure: Downstream non-invasive testing
timeFrame: 1- and 2-years.
measure: Downstream invasive testing
timeFrame: 1- and 2-years.
measure: Prevalence of obstructive CAD at ICA
timeFrame: 1- and 2-years.
measure: Revascularization
timeFrame: 1- and 2-years.
measure: Effective Dose
timeFrame: 1- and 2-years.
measure: Overall costs related to downstream diagnostic tests.
timeFrame: 1- and 2-years.
Other outcomes:
measure: Hospitalization for cardiac reason
timeFrame: 1- and 2-years.
measure: Unstable angina
timeFrame: 1- and 2-years.
measure: Non-fatal myocardial infarction
timeFrame: 1- and 2-years.
measure: Cardiac death
timeFrame: 1- and 2-years.
measure: MACE (Major adverse cardiovascular events)
timeFrame: 1- and 2-years.
measure: Cost-effectiveness ratio
timeFrame: 1- and 2-years.
Locations:
Study officials:
affiliation: Centro Cardiologico Monzino, IRCCS
name: Gianluca Pontone, MD, PhD
role: PRINCIPAL_INVESTIGATOR
affiliation: Medical University of South Carolina
name: U. Joseph Schoepf, MD
role: PRINCIPAL_INVESTIGATOR
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