Fractional Flow Reserve
Conditions
Keywords
Dobutamine stress echocardiography, Fractional flow reserve, Computed tomography-fractional flow reserve, Non-culprit lesions, Myocardial infarction, Lesion specific ischemia
Brief summary
Data are limited regarding the optimal treatment of the non-culprit lesions (NCL) after myocardial infarction (MI). The NON-CULPRIT study is a prospective cohort study with a primary aim to compare invasive fractional flow reserve (FFR) and dobutamine stress echocardiography (DSE) for the evaluation and treatment of NCL in patients with MI. As a secondary aim the investigators will assess the diagnostic performance of CT derived FFR as compared to invasive FFR and DSE measurements.
Detailed description
Myocardial ischemia and coronary artery disease (CAD) burden both provide valuable prognostic information for adverse cardiac events. More than 50% of patients with acute myocardial infarction have multi-vessel coronary artery disease. However current evidence regarding the optimal treatment of the non-culprit lesions (NCL) after myocardial infarction (MI) is still limited. The revascularization of NCL with at least moderate severity is associated with improved clinical outcomes, if significant ischemia was detected previously. Currently, there is no strict recommendation on the methods for detecting ischemia, therefore the current study aims to compare Dobutamine stress echocardiography (DSE) and invasive FFR for the evaluation and management of patients with MI and multi-vessel disease. DSE and FFR measurements will be perfomed in patinets with at least one intermediate NCL. If both results are positive (new wall motion abnormality of at least two segments related to the examined coronary artery on DSE and FFR≤0,8 are declared as positive), stent implantation will be performed, if both results are negative or in case of mismatch, optimal medical treatment will be chosen. Recent studies demonstrated the discrepancy between anatomical severity and hemodynamic relevance. Invasive fractional flow reserve (FFR) has emerged as the gold standard technique for the detection of lesion specific ischemia. The utilization of FFR in stable and acute chest pain patients can help in the selection of proper treatment strategy. The recently published Compare-Acute and DANAMI-Primulti trials have shown that in STEMI patients FFR-guided complete revascularization of NCL is beneficial as compared to infarct related lesion revascularization only. However, in light of recent studies involving post-MI patients, invasive FFR might be limited for the assessment of NCL due to vessel remodeling, microvascular changes and altered hemodynamics. Recent advancements in CT imaging allows for improved image quality and novel post-processing algorithms. Beyond anatomical data, functional information using coronary CT angiography (CTA) dataset and computational fluid dynamics simulations can be derived. CT derived FFR allows for the functional assessment of CAD in a non-invasive fashion. Data regarding the diagnostic accuracy of CT-FFR as compared to other widely utilized functional tests are limited. Also, high-risk plaque features might affect lesion specific ischemia as detected by invasive FFR. Coronary CTA plus CT-FFR may help to identify patients requiring revascularization, even with controversial DSE and FFR results.
Interventions
PROCEDURERevascularization
PCI or CABG
Sponsors
Bajcsy-Zsilinszky Hospital
Semmelweis University Heart and Vascular Center
Study design
Observational model
COHORT
Time perspective
PROSPECTIVE
Eligibility
Sex/Gender
ALL
Age
18 Years to 80 Years
Inclusion criteria
* Acute myocardial infarction * Moderate (40-80 %) stenosis of a non-culprit coronary artery * Signed informed consent
Exclusion criteria
* Age under 18 years * Age over 80 years * Incurable malignant disease * Patients for whom coronary CTA is contraindicated (History of severe and/or anaphylactic contrast reaction, severe renal insufficiency, inability to cooperate with scan acquisition and/or breathhold instructions)
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Acute myocardial infarction | From baseline to at least 2 years | Detection of a rise and/or fall of cardiac biomarker values \[preferably cardiac troponin (cTn)\] with at least one value above the 99th percentile upper reference limit (URL) and with at least one of the following: Symptoms of ischaemia. New or presumed new significant ST-segment-T wave (ST-T) changes or new left bundle branch block (LBBB). |
| Cardiovascular death | From baseline to at least 2 years | Death occurs due to cardiovascular cause |
| Target vessel revascularization | From baseline to at least 2 years | The Investigated Vessel needs Revascularisation due to angina |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Diagnostic performance of CT-FFR vs invasive FFR | From baseline to 3 months | Diagnostic performance of CT-FFR as compared to invasive FFR |
| Diagnostic performance of CT-FFR vs DSE | From baseline to 3 months | Diagnostic performance of CT-FFR as compared to DSE |
Countries
Hungary
Contacts
Primary ContactPeter Andrassy, MD PhD
Backup ContactBalazs Jablonkai, MD
Outcome results
None listed