Magnetic resonance perfusion or fractional flow reserve in coronary disease

Item Type:	Article
Title:	Magnetic resonance perfusion or fractional flow reserve in coronary disease
Creators Name:	Nagel, E. and Greenwood, J.P. and McCann, G.P. and Bettencourt, N. and Shah, A.M. and Hussain, S.T. and Perera, D. and Plein, S. and Bucciarelli-Ducci, C. and Paul, M. and Westwood, M.A. and Marber, M. and Richter, W.S. and Puntmann, V.O. and Schwenke, C. and Schulz-Menger, J. and Das, R. and Wong, J. and Hausenloy, D.J. and Steen, H. and Berry, C.
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. (Funded by the Guy's and St. Thomas' Biomedical Research Centre of the National Institute for Health Research and others; MR-INFORM ClinicalTrials.gov number, NCT01236807.).
Keywords:	Coronary Angiography, Coronary Artery Disease, Magnetic Resonance Angiography, Myocardial Fractional Flow Reserve, Risk Factors, Stable Angina
Source:	New England Journal of Medicine
ISSN:	0028-4793
Publisher:	Massachusetts Medical Society
Volume:	380
Number:	25
Page Range:	2418-2428
Date:	20 June 2019
Additional Information:	Copyright © 2019 Massachusetts Medical Society
Official Publication:	https://doi.org/10.1056/NEJMoa1716734
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