Cost and Quality-of-Life Outcomes of Fractional Flow Reserve With CT Angiography

Study Questions:

What is the effect on cost and quality of life (QOL) of using fractional flow reserve estimated using computed tomography (FFRCT) instead of usual care to evaluate stable patients with symptoms suspicious for coronary disease?

Methods:

The PLATFORM study investigators enrolled symptomatic patients without known coronary disease into two strata based on whether invasive or noninvasive diagnostic testing was planned. In each stratum, consecutive observational cohorts were evaluated with either usual care or FFRCT. The number of diagnostic tests, invasive procedures, hospitalizations, and medications during 90-day follow-up were multiplied by US cost weights and summed to derive total medical costs. Changes in QOL from baseline to 90 days were assessed using the Seattle Angina Questionnaire (SAQ), the EuroQOL (EQ-5D), and a visual analog scale (VAS).

Results:

In the 584 patients, 74% had atypical angina, and the pretest probability of coronary disease was 49%. In the planned invasive stratum, mean costs were 32% lower among the FFRCT patients than among the usual care patients ($7,343 vs. $10,734 p < 0.0001). In the noninvasive stratum, mean costs were not significantly different between the FFRCT patients and the usual care patients ($2,679 vs. $2,137, p = 0.26). In a sensitivity analysis, when the cost weight of FFRCT was set to 7 times that of CT angiography (CTA), the FFRCT group still had lower costs than in the usual care group in the invasive testing stratum ($8,619 vs. $10,734, p < 0.0001), whereas in the noninvasive testing stratum, when the cost weight of FFRCT was set to half that of CTA, the FFRCT group had higher costs than the usual care group ($2,766 vs. $2,137, p = 0.02). Each QOL score improved in the overall study population (p < 0.0001). In the noninvasive stratum, QOL scores improved more in FFRCT patients than in usual care patients: SAQ 19.5 vs. 11.4, p = 0.003; EQ-5D 0.08 vs. 0.03, p = 0.002; and VAS 4.1 vs. 2.3, p = 0.82. In the invasive cohort, the improvements in QOL were similar in the FFRCT and usual care patients.

Conclusions:

The authors concluded that an evaluation strategy based on FFRCT was associated with less resource use and lower costs within 90 days than evaluation with invasive coronary angiography.

Perspective:

This multicenter, prospective study of stable, symptomatic patients with suspected coronary disease reports that an evaluation strategy based on use of FFRCT was associated with lower use of medical resources and significantly lower costs compared with a strategy of invasive coronary angiography. Furthermore, a FFRCT-guided testing strategy was associated with less than half the rate of invasive coronary angiography, similar rates of overall coronary revascularization, and similar degrees of improvement in QOL than the invasive testing strategy. Overall, these findings suggest that the combination of anatomic and functional data provided by the FFRCT-guided testing strategy may lead to more selective use of invasive procedures than relying solely on the anatomic data provided by invasive coronary angiography. While this strategy appears attractive, it needs to be validated in a real-world population of patients including technical feasibility of FFRCT in all-comers.

Clinical Topics: Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Computed Tomography, Nuclear Imaging

Keywords: Angina Pectoris, Angiography, Coronary Angiography, Coronary Artery Disease, Diagnostic Imaging, Diagnostic Tests, Routine, Myocardial Ischemia, Quality of Life, Tomography, X-Ray Computed, Transcatheter Cardiovascular Therapeutics


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