CT FFR in stable heart disease and Coronary Computed Tomographic Angiography helps improve patient care and societal costs

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Abstract Background NHS England (NHSE) has advocated Coronary Computed Tomographic Angiography (CCTA) as the first line diagnostic test for suspected symptomatic coronary artery disease (CAD) since NICE Guidance in 2016 and CT Fractional Flow Reserve (CT FFR) as a second line test since 2017. In 2018 a national health technology programme funded CT FFR utilisation with the aim of improving patient pathways and reducing costs. Purpose To determine whether the introduction of a new technology (CT FFR) into the national health system improved patient care. Methods A multi-centre, observational analytic cohort study of all patients that underwent CCTA at 25 NHSE sites for the assessment of CAD over a 3-year period (April 2017- March 2020). Sites and patients were categorised as pre or post CT FFR health technology introduction. Clinical outcomes (all-cause death, myocardial infarction, cardiovascular death, revascularization) and resource utilization (downstream cardiac tests) were assessed at 2 years from NHS digital health records. Results 90,573 patients (Age 58.1±13.2, 51.9% male, 48.1% female), received 96,353 CCTA and 8,831 CT FFR as a second line test. Clinical characteristics were well matched between the 2 study groups (Figure 1). Results are presented as pre-CT FFR vs post-CT FFR with Odds Ratio (95% CI) for Post-CT FFR. No difference was observed for all-cause mortality (n=1135 (3.2%) vs 1627 (3.0%); OR 0.93 (0.86, 1.01), p=0.07) or Myocardial infarction events (n=348 (1.0%) vs 597 (1.1%); OR 1.12 (0.98, 1.28), p=0.10). Cardiovascular mortality was lower in the post CT FFR population (n=466 (1.3%) vs 628 (1.1%); OR 0.88 (0.78, 0.99), p=0.03) with higher rates of percutaneous intervention (PCI) (n=1866 (5.2%) vs 3069 (5.6%); OR 1.07 (1.01, 1.14), p=0.02 but not CABG (n=669 (1.9%) vs 993 (1.8%); OR 0.97 (0.87, 1.07), p=0.48). Figure 2. Fewer cardiac downstream tests were performed post CT-FFR (n=6356 (17.8%) vs 8073 (14.7%), p<0.001) including fewer invasive coronary angiograms (ICA) (n=4128 (11.6%) vs 5437 (9.9%); OR 0.84 (0.81, 0.88), p<0.001). Conclusion The introduction of CT FFR as a new technology on a national scale as part of a health intervention programme resulted in fewer cardiac downstream tests including fewer ICA. There was an associated increase in PCI but not CABG rates. All-cause mortality rates did not differ over time but CV mortality was significantly lower in the post-CT FFR population at 2 years.