Fractional Flow Reserve Versus Angiographically Guided Management to Optimise Outcomes in Unstable Coronary Syndromes (FAMOUS NSTEMI)
NonST Elevation Myocardial Infarction, Myocardial Infarction
About this trial
This is an interventional diagnostic trial for NonST Elevation Myocardial Infarction focused on measuring NonST elevation myocardial infarction (NSTEMI), Fractional flow reserve (FFR), Coronary angiogram, Diagnosis, Coronary revascularization, Prognosis, Health economics
Eligibility Criteria
Inclusion Criteria:
- NSTEMI with an elevated troponin (> upper limit of normal for local reference range) with at least one CAD risk factor (e.g. diabetes, age > 65 years, prior CAD, prior peripheral vascular disease, hypertension, hyperlipidaemia, family history of CAD).
- At least one coronary lesion ≥ 30% stenosis severity.
- Invasive management scheduled within 10 days of admission and ideally performed within 72 h of admission or a history of recurrent ischemic symptoms within 5 days.
Exclusion Criteria:
- On-going ischemic symptoms (i.e. chest pain) not controlled by medical therapy.
- Cardiogenic shock or hemodynamic instability.
- Angiographic exclusion: highly tortuous or calcified arteries, left main stenosis >80% angiographically (i.e. consistent with severe left main disease).
- Life expectancy of < 1 year.
- MI with persistent ST elevation.
- Intolerance to anti-platelet drugs.
- Unsuitable for either PCI or CABG on clinical or angiographic grounds.
- Coronary artery disease < 30% reference vessel diameter.
- Absence of a non-flow limiting coronary stenosis ≥30%.
- Non-coronary cardiac surgery (e.g. concomitant valve repair or replacement).
- Inability to give informed consent.
- Age < 18 years (no upper age limit).
Sites / Locations
- Golden Jubilee National Hospital
- Royal Blackburn Hospital
- University Hospital Southampton NHS Foundation Trust
- Hairmyres Hospital
- Freeman Hospital
- City Hospitals Sunderland NHS Foundation
Arms of the Study
Arm 1
Arm 2
Active Comparator
Placebo Comparator
Fractional flow reserve
Angiography-guided
Fractional flow reserve - guided group: The initial treatment decision and the coronary arteries for fractional flow reserve (FFR) measurement will be established and recorded before randomization. FFR will then be measured by the cardiologist immediately after randomization and the FFR result will used to guide treatment decisions based on a threshold of 0.80. An FFR ≤ 0.80 should result in a treatment decision for revascularization by PCI or CABG combined with optimal medical therapy and an FFR>0.80 should result in treatment with optimal medical therapy alone. Changes in treatment compared to the treatment plan prior to FFR disclosure will be recorded at the time.
FFR is measured by but not disclosed to the clinical team. Treatment decisions are therefore guided by angiography but not by FFR. The patient and the clinical team, including the cardiologists and nurses, will be blinded to FFR. The RadiAnalyzer Xpress (St Jude Medical) will be turned away from the clinical team who will not see the pressure wire data. FFR will not be displayed on any other monitor. Quality control checks, such as assessments of equalized pressure, will be done in the usual way, by the unblinded clinical research team. These steps will be followed for all FFR measurements. Adherence to the blinding protocol, including any non-protocol FFR disclosure at any time, will be prospectively recorded and blinding procedures will be monitored with site visits.