Abstract
Background
FFRCT assesses the functional significance of lesions seen on CTCA, and may be a more efficient
approach to chest pain evaluation. The FORECAST randomized trial found no significant
difference in costs within the UK National Health Service, but implications for US
costs are unknown. The purpose of this study was to compare costs in the FORECAST
trial based on US healthcare cost weights, and to evaluate factors affecting costs.
Methods
Patients with stable chest pain were randomized either to the experimental strategy
(CTCA with selective FFRCT), or to standard clinical pathways. Pre-randomization, the treating clinician declared
the planned initial test. The primary outcome was nine-month cardiovascular care costs.
Results
Planned initial tests were CTCA in 912 patients (65%), stress testing in 393 (28%),
and invasive angiography in 94 (7%). Mean US costs did not differ overall between
the experimental strategy and standard care (cost difference +7% (+$324), CI −12%
to +26%, p = 0.49). Costs were 4% lower with the experimental strategy in the planned
invasive angiography stratum (p for interaction = 0.66). Baseline factors independently
associated with costs were older age (+43%), male sex (+55%), diabetes (+37%), hypertension
(+61%), hyperlipidemia (+94%), prior angina (+24%), and planned invasive angiography
(+160%). Post-randomization cost drivers were coronary revascularization (+348%),
invasive angiography (267%), and number of tests (+35%).
Conclusions
Initial evaluation of chest pain using CTCA with FFRCT had similar US costs as standard care pathways. Costs were increased by baseline
coronary risk factors and planned invasive angiography, and post-randomization invasive
procedures and the number of tests.
Registration at ClinicalTrials.gov (NCT03187639).
Keywords
Abbreviations:
CI (95% confidence interval), CTCA (Computed tomography coronary angiography), FFR (Fractional flow reserve), FFRCT (Fractional flow reserve derived from computed tomography coronary angiography), FORECAST (Fractional Flow Reserve Derived from Computed Tomography Coronary Angiography in the Assessment and Management of Stable Chest Pain), PLATFORM (Prospective Longitudinal Trial of FFRCT: Outcomes and Resource Impacts), UK (United Kingdom), US (United States)To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
Full access to the journal is a member benefit for SCCT Members, Login via the SCCT website to access all journal content.
Subscribe:
Subscribe to Journal of Cardiovascular Computed TomographyAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the diagnosis and management of patients with stable ischemic heart disease.J Am Coll Cardiol. 2012; 60: e44-e164
- Outcomes of anatomical versus functional testing for coronary artery disease.N Engl J Med. 2015; 372: 1291-1300
- 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain: a report of the American College of Cardiology/American heart association Joint Committee on clinical practice guidelines.Circulation. 2021; 144: e368-e454
- Computational fluid dynamics applied to cardiac computed tomography for noninvasive quantification of fractional flow reserve: Scientific basis.J Am Coll Cardiol. 2013; 61: 2233-2241
- Does the routine availability of CT-derived FFR influence management of patients with stable chest pain compared to CT angiography alone?: the FFR CT RIPCORD Study.JACC Cardiovasc Imaging. 2016; 9: 1188-1194
- Cost-effectiveness analysis of anatomic vs functional index testing in patients with low-risk stable chest pain.JAMA Netw Open. 2020; 3e2028312
- Diagnostic performance of noninvasive fractional flow reserve derived from coronary computed tomography angiography in suspected coronary artery disease: the NXT trial (Analysis of coronary blood flow using CT angiography: next steps).J Am Coll Cardiol. 2014; 63: 1145-1155
- Comparison of coronary computed tomography angiography, fractional flow reserve, and perfusion imaging for ischemia diagnosis.J Am Coll Cardiol. 2019; 73: 161-173
- Clinical outcomes of fractional flow reserve by computed tomographic angiography-guided diagnostic strategies vs. usual care in patients with suspected coronary artery disease: the prospective longitudinal trial of FFRCT: outcome and resource impacts study.Eur Heart J. 2015; 36: 3359-3367
- Quality-of-life and economic outcomes of assessing fractional flow reserve with computed tomography angiography: PLATFORM.J Am Coll Cardiol. 2015; 66: 2315-2323
- 1-Year Impact on medical practice and clinical outcomes of FFR CT: the ADVANCE registry.JACC Cardiovasc Imaging. 2020; 13: 97-110
- Fractional flow reserve derived from computed tomography coronary angiography in the assessment and management of stable chest pain: rationale and design of the FORECAST trial.Cardiovasc Revascularization Med. 2020; 21: 890-896
- Fractional flow reserve derived from computed tomography coronary angiography in the assessment and management of stable chest pain: the FORECAST trial.Eur Heart J. 2021; 42: 3844-3852
National Institute for Health & Clinical Excellence. Recent-onset Chest Pain of Suspected Cardiac Origin: Assessment and Diagnosis. Clinical guideline [CG95]. Published date: 24 March 2010 Last updated: 30 November 2016.
- Selective referral using CCTA versus direct referral for individuals referred to invasive coronary angiography for suspected CAD: a randomized, controlled, open-label trial.JACC Cardiovasc Imaging. 2019; 12: 1303-1312
- Assessing the value of coronary artery computed tomography as the first-line anatomical test for stable patients with indications for invasive angiography due to suspected coronary artery disease. Initial cost analysis in the CAT-CAD randomized trial.J Cardiovasc Comput Tomogr. 2020; 14: 75-79
- CT or invasive coronary angiography in stable chest pain.N Engl J Med. 2022; 386: 1591-1602
Article info
Publication history
Published online: September 24, 2022
Accepted:
September 21,
2022
Received in revised form:
August 22,
2022
Received:
June 8,
2022
Identification
Copyright
© 2022 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.
