Nagel, E. et al. (2019) Magnetic resonance perfusion or fractional flow reserve in coronary disease. New England Journal of Medicine, 380(25), pp. 2418-2428. (doi: 10.1056/NEJMoa1716734) (PMID:31216398)
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Abstract
Background: In patients with stable angina, two strategies are often used to guide revascularization: one involves myocardial-perfusion cardiovascular magnetic resonance imaging (MRI), and the other involves invasive angiography and measurement of fractional flow reserve (FFR). Whether a cardiovascular MRI–based strategy is noninferior to an FFR-based strategy with respect to major adverse cardiac events has not been established. Methods: We performed an unblinded, multicenter, clinical-effectiveness trial by randomly assigning 918 patients with typical angina and either two or more cardiovascular risk factors or a positive exercise treadmill test to a cardiovascular MRI–based strategy or an FFR-based strategy. Revascularization was recommended for patients in the cardiovascular-MRI group with ischemia in at least 6% of the myocardium or in the FFR group with an FFR of 0.8 or less. The composite primary outcome was death, nonfatal myocardial infarction, or target-vessel revascularization within 1 year. The noninferiority margin was a risk difference of 6 percentage points. Results: A total of 184 of 454 patients (40.5%) in the cardiovascular-MRI group and 213 of 464 patients (45.9%) in the FFR group met criteria to recommend revascularization (P=0.11). Fewer patients in the cardiovascular-MRI group than in the FFR group underwent index revascularization (162 [35.7%] vs. 209 [45.0%], P=0.005). The primary outcome occurred in 15 of 421 patients (3.6%) in the cardiovascular-MRI group and 16 of 430 patients (3.7%) in the FFR group (risk difference, −0.2 percentage points; 95% confidence interval, −2.7 to 2.4), findings that met the noninferiority threshold. The percentage of patients free from angina at 12 months did not differ significantly between the two groups (49.2% in the cardiovascular-MRI group and 43.8% in the FFR group, P=0.21). Conclusions: Among patients with stable angina and risk factors for coronary artery disease, myocardial-perfusion cardiovascular MRI was associated with a lower incidence of coronary revascularization than FFR and was noninferior to FFR with respect to major adverse cardiac events.
| Item Type: | Articles |
|---|---|
| Status: | Published |
| Refereed: | Yes |
| Glasgow Author(s) Enlighten ID: | Berry, Professor Colin |
| Authors: | Nagel, E., Greenwood, J. P., McCann, G. P., Bettencourt, N., Shah, A. M., Hussain, S. T., Perera, D., Plein, S., Bucciarelli-Ducci, C., Paul, M., Westwood, M. A., Marber, M., Richter, W.-S., Puntmann, V. O., Schwenke, C., Schulz-Menger, J., Das, R., Wong, J., Hausenloy, D. J., Steen, H., and Berry, C. |
| College/School: | College of Medical Veterinary and Life Sciences > School of Cardiovascular & Metabolic Health |
| Journal Name: | New England Journal of Medicine |
| Publisher: | Massachusetts Medical Society |
| ISSN: | 0028-4793 |
| ISSN (Online): | 1533-4406 |
| Copyright Holders: | Copyright © 2019 Massachusetts Medical Society |
| First Published: | First published in New England Journal of Medicine 380(25):2418-2428 |
| Publisher Policy: | Reproduced in accordance with the copyright policy of the publisher |
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