Personalized Evaluation of Susptected Myocardial Ischemia
NCT ID: NCT06708000
Last Updated: 2025-12-19
Study Results
The study team has not published outcome measurements, participant flow, or safety data for this trial yet. Check back later for updates.
Basic Information
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ENROLLING_BY_INVITATION
PHASE3
2000 participants
INTERVENTIONAL
2024-11-20
2027-12-31
Brief Summary
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Detailed Description
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At Gødstrup Hospital, novel clinical likelihood (CL) models have been developed to assess the pre-test probability of obstructive CAD. Based on sex, age, and symptom characteristics, and including traditional cardiovascular risk factors, the risk factor-weighted clinical likelihood (RF-CL) model improves discrimination of obstructive CAD and prognosis compared to traditional models. Additionally, the utilization of a coronary artery calcium score (CACS) in conjunction with the RF-CL model, i.e., the CACS-weighted clinical likelihood (CACS-CL) model, further enhances patient management in external validation cohorts. Recently, both CL models have been implemented in the European guidelines on CAD management. However, the CL models have only been applied in observational studies, and no randomized trials substantiate their use in clinical practice.
It is hypothesized that a diagnostic strategy based on an assessment including the CL models is non-inferior to the current standard strategy, as measured by the number of asymptomatic patients during follow-up. Secondly, it is assumed that the CL-based strategy reduces unnecessary diagnostic tests and improve resource utilization without compromising patient safety.
Emerging alongside these developments is Laser Speckle Contrast Imaging (LSCI), a promising non-invasive technique for assessing microvascular function. Several studies have suggested a link between reduced microcirculation in the skin and heart among patients with angina and non-significant calcification, compared to healthy controls. LSCI measures red blood cell movement to quantify blood flow, making it an effective, fast, and cost-efficient tool already in use in other medical fields. If a correlation between peripheral and cardiac microcirculation is established, LSCI could address a diagnostic gap in detecting microvascular dysfunction, particularly for angina patients without significant coronary calcification. Integrating LSCI into the diagnostic process offers potential to further refine patient selection for testing and provide more targeted diagnostic pathways.
This study will increase the evidence for utilizing the RF-CL and CACS-CL models in clinical practice. Currently, the use of pre-test likelihood models is only recommended with a IB recommendation and deferral of diagnostic testing in individuals with CL\>=5% with IIa B recommendation due to a lack of randomized studies. The study will focus on symptomatic endpoints and investigate quality of life measurements in patients deferred for testing based on the CL estimation. Secondary endpoints include both effectiveness and safety metrics.
This project is an ambitious endeavor that builds on previous work performed within our research group. The supervisors are experienced researchers with substantial expertise in this area and conducting randomized studies. The findings from this study have the potential to significantly impact clinical practice by providing evidence-based recommendations (Level/Class of evidence 1A) for the use of CL models in the diagnostic pathway of ischemic heart disease.
By demonstrating that using the CL model in the management of patients with new-onset chest pain substantially and safely reduces the necessity for cardiac CT and other advanced diagnostic procedures, resource utilization could improve and costs be lowered for the healthcare system. Additionally, as tests could be deferred without compromising safety, patient-related quality of life could improve. Finally, the findings are expected to contribute to clinical guidelines and practices, benefiting the broader field of cardiology. By validating the CL models in a large, diverse patient population, this study could provide strong evidence for their broader implementation in clinical practice.
The incorporation of LSCI into this framework also presents an exciting avenue for further improving diagnostic precision. If LSCI can reliably identify microvascular dysfunction, it could serve as a complementary tool in optimizing diagnostic strategies, particularly for patients in whom obstructive CAD has been ruled out but who still experience angina-like symptoms.
If CL model utilization proves capable of safely reducing the necessity for CCTA and other advanced diagnostic procedures in patients with obstructive CAD, resource utilization could improve, lowering costs for the healthcare system while maintaining or enhancing patient quality of life.
The present research addresses a significant gap in current diagnostic strategies and has the potential to shift clinical practices towards more personalized and efficient care pathways for stable chest pain.
Conditions
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Keywords
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Study Design
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RANDOMIZED
PARALLEL
DIAGNOSTIC
SINGLE
Then, patients will be randomly assigned to either the control group or the intervention group, and regardless of study allocation and initial RF-CL assessement, all patients will then receive an initially blinded CCTA. The cardiologist conducting the CCTA is unaware of the patient's randomization status.
Patients in the intervention group with a clinical likelihood of obstructive CAD (RF-CL) ≤5% will receive a blinded CCTA.
Patients in the intervention group with RF-CL \>5% will undergo a CACS assessment to estimate a CACS-CL.
Patients in the control group, and patients in the intervention group with a CL \>5%, will receive their test results, including unblinding of the results from the CCTA.
Patients in the intervention group with CL≤5% will also receive their test results, except for the CCTA results which remain blinded.
The interviewer at follow-up is unaware of the CCTA result.
Study Groups
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Clinical Likelihood-Based Diagnostic Strategy
Patients in this arm will be assessed using the Clinical Likelihood (CL) models, including the Risk Factor-Weighted Clinical Likelihood (RF-CL) and Coronary Artery Calcium Score-Weighted Clinical Likelihood (CACS-CL) models.
Clinical Likelihood (CL) Model-Based Diagnostic Strategy
The Clinical Likelihood (CL) model-based diagnostic strategy utilizes two models: the RF-CL model and the CACS-CL model. These models assess the pre-test probability of obstructive coronary artery disease (CAD) based on patient factors such as age, sex, symptoms, and traditional cardiovascular risk factors like smoking, diabetes, and hypertension. The CACS-CL model incorporates coronary artery calcium scoring to further refine the risk assessment. Patients identified with a low likelihood of CAD may avoid unnecessary diagnostic testing, such as cardiac CT, while maintaining diagnostic accuracy and safety. This approach aims to optimize resource use, reduce patient burden, and focus on other potential causes of symptoms when CAD is unlikely.
Standard of Care
Patients in this arm will follow the standard diagnostic pathway.
Standard of care treatment
Patients will follow the standard diagnostic pathway, which includes the use of cardiac CT and other advanced diagnostic procedures based on clinical guidelines. This approach is the current standard of care for patients with suspected obstructive coronary artery disease (CAD). The control group allows for comparison of outcomes with those in the intervention arm, particularly in terms of resource utilization, patient safety, and diagnostic accuracy.
Interventions
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Clinical Likelihood (CL) Model-Based Diagnostic Strategy
The Clinical Likelihood (CL) model-based diagnostic strategy utilizes two models: the RF-CL model and the CACS-CL model. These models assess the pre-test probability of obstructive coronary artery disease (CAD) based on patient factors such as age, sex, symptoms, and traditional cardiovascular risk factors like smoking, diabetes, and hypertension. The CACS-CL model incorporates coronary artery calcium scoring to further refine the risk assessment. Patients identified with a low likelihood of CAD may avoid unnecessary diagnostic testing, such as cardiac CT, while maintaining diagnostic accuracy and safety. This approach aims to optimize resource use, reduce patient burden, and focus on other potential causes of symptoms when CAD is unlikely.
Standard of care treatment
Patients will follow the standard diagnostic pathway, which includes the use of cardiac CT and other advanced diagnostic procedures based on clinical guidelines. This approach is the current standard of care for patients with suspected obstructive coronary artery disease (CAD). The control group allows for comparison of outcomes with those in the intervention arm, particularly in terms of resource utilization, patient safety, and diagnostic accuracy.
Eligibility Criteria
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Inclusion Criteria
* Patients capable of providing written informed consent
Exclusion Criteria
* Known ischemic heart disease, including previous PCI (with or without stent) and bypass surgery
* Unstable angina pectoris at initial consultation
* Severe COPD or asthma
* Severe valvular disease
* Absolute or relative contraindications for Cardiac CT:
* allergy to iomeron
* pregnant women, including women who are potentially pregnant or lactating
* reduced kidney function with an estimated glomerular filtration rate \<40 ml/min
* LVEF \<45%
30 Years
75 Years
ALL
No
Sponsors
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Gødstrup Hospital
OTHER
Responsible Party
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Locations
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Regional Hospital of Godstrup
Herning, , Denmark
Countries
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References
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Winther S, Schmidt SE, Mayrhofer T, Botker HE, Hoffmann U, Douglas PS, Wijns W, Bax J, Nissen L, Lynggaard V, Christiansen JJ, Saraste A, Bottcher M, Knuuti J. Incorporating Coronary Calcification Into Pre-Test Assessment of the Likelihood of Coronary Artery Disease. J Am Coll Cardiol. 2020 Nov 24;76(21):2421-2432. doi: 10.1016/j.jacc.2020.09.585.
Brix GS, Rasmussen LD, Rohde PD, Schmidt SE, Nyegaard M, Douglas PS, Newby DE, Williams MC, Foldyna B, Knuuti J, Bottcher M, Winther S. Calcium Scoring Improves Clinical Management in Patients With Low Clinical Likelihood of Coronary Artery Disease. JACC Cardiovasc Imaging. 2024 Jun;17(6):625-639. doi: 10.1016/j.jcmg.2023.11.008. Epub 2024 Jan 3.
Rasmussen LD, Fordyce CB, Nissen L, Hill CL Jr, Alhanti B, Hoffmann U, Udelson J, Bottcher M, Douglas PS, Winther S. The PROMISE Minimal Risk Score Improves Risk Classification of Symptomatic Patients With Suspected CAD. JACC Cardiovasc Imaging. 2022 Aug;15(8):1442-1454. doi: 10.1016/j.jcmg.2022.03.009. Epub 2022 May 11.
Rasmussen LD, Williams MC, Newby DE, Dahl JN, Schmidt SE, Bottcher M, Winther S. External validation of novel clinical likelihood models to predict obstructive coronary artery disease and prognosis. Open Heart. 2023 Dec 6;10(2):e002457. doi: 10.1136/openhrt-2023-002457.
Vrints C, Andreotti F, Koskinas KC, Rossello X, Adamo M, Ainslie J, Banning AP, Budaj A, Buechel RR, Chiariello GA, Chieffo A, Christodorescu RM, Deaton C, Doenst T, Jones HW, Kunadian V, Mehilli J, Milojevic M, Piek JJ, Pugliese F, Rubboli A, Semb AG, Senior R, Ten Berg JM, Van Belle E, Van Craenenbroeck EM, Vidal-Perez R, Winther S; ESC Scientific Document Group. 2024 ESC Guidelines for the management of chronic coronary syndromes. Eur Heart J. 2024 Sep 29;45(36):3415-3537. doi: 10.1093/eurheartj/ehae177. No abstract available.
Other Identifiers
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1-10-72-47-24
Identifier Type: -
Identifier Source: org_study_id