ESC Congress 2016 - 26

clINIcAl TRIAl HIgHlIgHTs for revascularization and had a CHD PTL of 10%-90%. Patients with nonanginal chest pain or prior cardiac procedures were excluded. The primary endpoint was unnecessary invasive coronary angiography occurring within 12 months, defined by a normal (> 0.8) fractional flow reserve value or quantitative coronary angiography [QCA]) in all vessels ≥ 2.5 mm in diameter. Secondary endpoints were positive angiogram rates, and major adverse cardiac event (MACE; cardiovascular [CV] death, myocardial infarction, unplanned coronary revascularization, and hospital admission for a CV cause). Participants were randomized to receive CMR (n = 481), MPS-SPECT (n = 481), or NICE (n = 240) guided-care and were included in the analysis according to their assigned arm [Ripley DP et al. Am Heart J. 2015]. The study population (mean age 56.3 years; 46.9% women) had a substantial burden of CV risk factors and reported chest pain as their primary symptom. At baseline the mean (SD) PTL was 49.5% (23.8%). After 12 months of follow-up, 22.0% of patients underwent angiography (NICE 42.5%, CMD 17.7%, and MPS 16.2%). Study-defined unnecessary angiography rates were NICE 28.8%, CMR 7.5%, and MPS 7.1%. The adjusted odds ratio of unnecessary invasive angiography for CMR vs NICE guided care was 0.21 (95% CI, 0.12 to 0.34; P < .001) and 1.27 for CMR vs MPS (95% CI, 0.79 to 2.03; P = .32). Positive angiography rates were 12.1%, 9.8%, and 8.7% and in the NICE, CMR, and MPSSPECT guided-care arms, respectively (P = .36). After a minimum of 1-year follow-up, 36 (3.0%) patients had at least one MACE (Figure 1), but there was no difference in MACE rates between the 3 groups. The use of functional imaging first line (CMR or MPS) reduces the odds of unnecessary angiography compared with a NICE guidelines-based strategy (OR, 0.048; 95% CI, 0.023 to 0.10; P < .001) in patients with 61%-90% (high) PTL of CHD. Prof Greenwood concluded that in patients with suspected angina, investigation by CMR produced a lower probability of unnecessary angiography, than NICE guideline-directed care. There was no significant difference between CMR- and MPS-SPECT-guided approaches and there were no significant differences in 12-month MACE rates among the 3 strategies. PET Best Imaging Tool for Diagnosis of Myocardial Ischemia: The PACIFIC Trial Written by Maria Vinall Ibrahim Danad, MD, Vu University Medical Center, Amsterdam, The Netherlands, reported late-breaking results from the PACIFIC trial indicating that positron emission tomography (PET) imaging is more accurate than either single-photon emission computed tomography (SPECT) or coronary computed tomography angiography (CCTA) for the diagnosis of coronary artery disease (CAD). Figure 1. No Difference in Time to First MACE Among Treatment Arms 10 nice-guided cMr-guided MPs-guided care (n = 240) care (n = 481) care (n = 481) Mace events (patients) CMR MPS NICE 9 CMR vs NICE HR, 1.37 (0.52, 3.57) P = .52 8 Cumulative MACE Rate total (n = 1202) 7 6 44 (36) 7 (6) 20 (15) 17 (15) cardiovascular death 5 1 1 3 Myocardial infarction 9 2 5 2 revascularization - unplanned Pci 12 3 6 4 revascularization - unplanned caBg 1 - 1 - 1 arrhythmia 9 2 4 3 0 heart failure 4 - - 4 stroke/tia 4 - 3 1 CMR vs MPS HR, 0.95 (0.46, 1.95) P = .88 5 4 3 2 CMR MPS NICE 0 6 481 481 240 472 467 235 12 18 24 Months Since Randomization 30 36 463 461 233 98 97 50 28 29 17 367 372 187 237 241 121 CMR, cardiovascular magnetic resonance; CABG, coronary artery bypass graft; MPS, myocardial perfusion scintigraphy; MACE, major adverse cardiac event; NICE, National Institute of Care Excellence. Reproduced from Greenwood JP et al. Effect of Care Guided by Cardiovascular Magnetic Resonance, Myocardial Perfusion Scintigraphy, or NICE Guidelines on Subsequent Unnecessary Angiography Rates. The CE-MARC 2 Randomized Clinical Trial. JAMA. 2016; doi:10.1001/jama.2016.12680. Copyright © 2016 American Medical Association. All rights reserved. 26 October 2016 medicom-publishers.com/mcr http://www.medicom-publishers.com/mcr

Table of Contents for the Digital Edition of ESC Congress 2016