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Hello, everybody.

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Uh, my name's James Udelson.

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I'm chief of cardiology at Tufts Medical

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Center in, uh, Boston.

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And I'm joined for our conference this morning

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by Michelle Kelsey from Duke

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and Timothy Fairburn from Liverpool,

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who will introduce more formally in a couple of minutes.

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And we're here today to talk about transformational data

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and new paradigms evaluating stable chest pain

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with coronary CTA for World Heart Day.

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The learning objectives are listed here.

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We're interested in increasing global awareness

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for advances in cardiovascular disease diagnosis

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specifically for coronary disease.

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To share the latest data on why

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to potentially choose CCTA first for patients

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with stable chest pain, we'll discuss strategies

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to safely defer testing in low-risk patients.

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Explore the benefits of a CT A plus

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C-T-F-F-R diagnostic pathway.

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Understand how the CCTA pathway enables clinicians

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to take more informed and expedited patient care decisions

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and defined methods to improve cath lab efficiency

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and reduce unnecessary cardiovascular tests.

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As you know, clinical guidelines outline optimal care

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pathways for patients, and there's been a plethora

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of guidelines, um, over the years,

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including some very recent ones here in

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the United States and Europe.

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Over time, the goals have evolved

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and include on the right, reduce unnecessary testing,

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improving the diagnostic yield of testing

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and catheterization to improve efficiency

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of patient selection, reduce complications and costs,

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and optimize preventative medical treatments.

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Relatively recently in 2021, the American College

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of Cardiology and American Heart Association,

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chest Pain Guidelines elevated coronary CTA

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as the only class one non-invasive test

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with level A evidence for diagnosing CAD

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and guiding treatment decisions.

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And this is if you live here in the us, you know,

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it's quite a difference from the many years

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where we would get pushback, uh, from payers, uh,

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because there was no evidence.

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Now, there's level A evidence, an enormous amount

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of randomized clinical trial data,

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and you'll see some of that as well today, as well as,

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as some big data from observational, uh, databases.

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So the, the recommendation, uh, uh, level one, a evidence

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for intermediate risk patients with stable chest pain

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and suspected CAD, that is no known CAD, uh, coronary CTA,

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is effective for diagnosis of coronary disease,

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for risk stratification,

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and for guiding treatment decisions.

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So, in other words, this enables clinicians

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to take informed action.

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Here is a table from, um,

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the current US guidelines here in the middle with,

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you can see hopefully the laser pointer in the intermediate

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and high risk patients.

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Uh, CTA is a one a level of evidence.

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Uh, very occasionally it's inconclusive

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and you move on to stress testing.

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If there's non-obstructive CAD if it's intermediate, then

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TFFR can be done.

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Or if there's obstructive CAD, that's still some question

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as its physiologic significance, C-T-F-F-R, uh, can be done.

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High risk CAD moves on to, um,

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invasive coronary angiography.

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And on the right here, the stress testing paradigm, moderate

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to severe ischemia can be treated

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with guideline directed medical therapy

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in general based on the ischemia trial.

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And then either continued

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or move on to ICA based on symptom relief.

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So that's in the big picture, uh, the current general

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paradigm, at least here in the United States.

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Well, right now, I'd like to turn it over, um,

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for our first talk to Michelle Kelsey.

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Michelle is an assistant professor

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of medicine in the Department of Medicine

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and the vision of cardiology at Duke University in, uh,

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North Carolina here in the us.

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And she's gonna talk to us about some very recent randomized

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trial data published, uh, just a month

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or so ago in JAMA Cardiology from the Precise

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trial. Michelle, take it away.

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Thank you so much, Dr. Delson.

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It's my pleasure to be here talking

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to you guys about the precise trial, um,

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which was presented at a HA

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and was published recently in JAMA Cardiology.

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And you can see the citation on the screen.

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I wanna spend our time today talking a little bit about the

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structure and design of precise, um,

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and the results of precise.

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I wanna talk about what we can learn from the precise trial

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data about the role that CT with FFR can have in the workup

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of chest pain, um, in processes

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of care and in clinical care.

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And I wanna spend a little bit of time talking about

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what we can learn from precise in terms of the management

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of low risk patients.

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Well, I wanna ground our conversation today in a case.

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So this is a 52-year-old woman who presented for evaluation

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of dyspnea exertion.

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Um, she went to her primary care provider

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and was initially suspected to have asthma that was kind

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of compounded by anxiety or panic.

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Um, and she was treated with inhalers when

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her symptoms persisted.

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She was referred to cardiology for further evaluation

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where we sent her for a coronary CT with FFR ct.

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Though the precise trial looked at patients not unlike the

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one I just presented, stable patients with type symptoms,

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so DYS, exertion

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or chest pain, some sort of symptoms suggestive

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of cardiovascular etiology.

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These were people with no known history

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of prior coronary disease

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who had not had any recent cardiovascular

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testing in the last year.

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And these were patients who were gonna be referred

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for some sort of non-emergent stress testing

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or invasive coronary angiography.

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Um, and patients were randomized

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to one of two interventions.

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So first was traditional testing,

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which is essentially usual care.

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It was whatever stress test that their,

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that their provider was planning to order,

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whether it was stress, echo stress, nuclear, um,

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invasive coronary angiography.

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Um, and, and that that was sort of standard of care arm.

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In the precision pathway arm patients were first evaluated

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with risk stratification,

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and so they were risk stratified using the Promise minimal

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risk tool, which is a calculator

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that was derived from the PROMISE trial designed

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to identify patients at low risk.

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Um, so if, if patients in precision were deemed elevated

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risk by this tool, they were referred

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for a coronary CT with FFR.

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And if they were deemed low risk by this tool,

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they were offered kind of

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guideline directed medical therapy.

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They were offered kind of reassurance by their provider, um,

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and they were not immediately referred for testing.

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Um, so deferred testing in this,

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in this particular population,

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and all of these groups were followed for a year

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for a composite primary endpoint that has two parts

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clinical events, so death or nonfatal mi

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and a process of care, kind of clinical efficiency outcome,

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um, which is cath without obstructive coronary disease.

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So essentially heart catheterization

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that was not necessarily needed.

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This is kind of a smattering of what happened with testing

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and precise between the two arms.

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So on the right is traditional testing,

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and you can see that participants in this arm got a variety

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of different stress tests, uh, stress, nuclear stress, echo

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treadmill, EKG, um, some were referred direct to cath,

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which is within their provider's discretion.

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And in the precision arm

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and the precision pathway arm, you can see

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that the majority received coronary ct.

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Those that had a stenosis that kind

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of merited further evaluation were also underwent

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FFR CT testing.

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And then you can see the light blue piece

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of the pie, which is no testing.

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Um, so a certain proportion

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of these people in the precision pathway arm, um,

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didn't end up getting any kind of testing.

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And I'll remind you that some of this is by design

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as the participants that were low risk,

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were offered deferred testing initially,

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and some never went on to getting any kind of test.

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So how did people do? So the precision pathway showed a 70%

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reduction in our composite primary endpoint compared

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to traditional testing at one year.

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Um, so I'll remind you again,

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our endpoint was clinical events, death and non-fatal MI

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and processes of care, kind of clinical efficiency outcomes,

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which was cath without obstructive disease.

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Um, and the precision pathway, uh,

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folks did better than traditional testing at a

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year out from this regard.

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I wanna break down a little bit into some

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of the details of the trial.

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'cause I think this helps us, um, understand the role

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that coronary CT with FFR can have in, in processes of care

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and the workup of chest pain.

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And so in the precision pathway arm, about 13%

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of participants underwent heart catheterization.

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Um, and among this 13%, 80% were diagnosed

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with obstructive coronary disease.

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So relatively high yield cath findings

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in traditional testing, about 17% underwent catheterization

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and only 40% were found

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to have obstructive coronary disease.

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So pretty different figure there in terms of yield of,

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of catheterization,

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and I think there are probably multiple reasons for this,

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but I would say that, you know, one of the things

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that coronary CT gives us is this anatomic definition, um,

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helps us kind of select the right patients to go on to non

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to to more invasive testing, helps us kind

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of identify the people that are at high risk

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or identify people that need like invasive definition

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of their coronary disease.

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Another statistic from the precise trial.

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Um, so when we looked at the number of non-invasive tests

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that people were receiving,

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so this is two non-invasive tests in a row,

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that figure was about 10% in traditional testing

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and was about 3.5% in the precision pathway arm.

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So there were quite a few people in traditional testing

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that had more than one kind of non-invasive stress test.

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And, you know, we don't know the reasons for all

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of these kind of layered tests.

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It may be that there was a change in the participant's

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clinical status that merited additional testing.

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Um, but a, as a practicing cardiologist, I I suspect

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that some of them are related to getting kind

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of equivocal results from the first test.

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Um, and then, and then needing a second test to confirm

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or having sort of a positive treadmill, EKG

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or equivocal treadmill EKG,

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and then going on to testing with imaging.

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Um, so less of that happen in precision,

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um, compared to traditional.

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And then the last thing I'll say is that, um,

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revascularization was higher in precision pathway compared

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to traditional testing, about 9% compared to about 5.4%.

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And we've seen this in other literature on coronary CT

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that revascularization is, is usually higher

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after coronary ct.

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And, and this is kind of consistent with that data.

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What I will say is that all

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but one of the revascularizations performed in the trial

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were deemed to be kind of ischemia driven, um,

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which was an adjudicated endpoint, um, by a,

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by a separate blinded party.

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One other point about the precise trial,

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which I think is really important,

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and again, highlights something

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that I think coronary CT is very useful for is we followed,

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um, medication use over the course of the trial.

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And individuals in the precision arm were more likely

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to get liquid lowering therapy

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and more likely to get anti-platelet agents.

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You know, I think part of the reason for this is

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that when you get a coronary CT

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and you diagnose non-obstructive disease,

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you may have had a normal stress echo, um,

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but you get some additional anatomic information from the ct

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and that helps kind of guide medical care.

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And I think it makes people a little bit more aggressive

263
00:11:40.285 --> 00:11:42.285
about preventive therapy, um,

264
00:11:42.305 --> 00:11:43.885
and also helps them sort

265
00:11:43.885 --> 00:11:46.405
of guide appropriate anti-platelet use,

266
00:11:46.405 --> 00:11:47.645
which I think is very important.

267
00:11:49.035 --> 00:11:52.015
So I wanna spend our last few minutes together talking a

268
00:11:52.015 --> 00:11:54.325
little bit about the low risk participants

269
00:11:54.345 --> 00:11:57.005
and I'll, I'll just remind you from our first slide together

270
00:11:57.475 --> 00:12:00.525
that a certain percentage of patients in precise

271
00:12:00.745 --> 00:12:03.845
who were deemed low risk by the promise, minimal risk score

272
00:12:04.355 --> 00:12:06.725
were offered medical therapy and reassurance

273
00:12:06.745 --> 00:12:08.285
and not immediately referred to testing.

274
00:12:08.815 --> 00:12:11.845
These folks could, if they had escalation in their symptoms

275
00:12:11.905 --> 00:12:13.165
or worsening of symptoms,

276
00:12:13.675 --> 00:12:15.765
they could request testing down the line,

277
00:12:15.785 --> 00:12:17.485
but were not immediately sent to testing.

278
00:12:18.545 --> 00:12:20.605
And precise showed us that actually these,

279
00:12:20.615 --> 00:12:22.005
these people do very well.

280
00:12:22.305 --> 00:12:25.285
So in terms of the precise primary endpoint,

281
00:12:25.285 --> 00:12:26.525
which was death, MI

282
00:12:26.525 --> 00:12:29.125
and Cath, that obstructive disease, um,

283
00:12:29.125 --> 00:12:31.805
individuals in the precision arm did better than low risk

284
00:12:31.805 --> 00:12:33.765
individuals in the traditional testing arm.

285
00:12:34.115 --> 00:12:36.965
Kind of analogous to the overall results from the trial.

286
00:12:37.705 --> 00:12:39.365
But what I think is also very important

287
00:12:39.495 --> 00:12:42.125
among this subgroup is they actually did very well from a

288
00:12:42.325 --> 00:12:43.445
clinical standpoint as well.

289
00:12:43.535 --> 00:12:47.085
There was no death and no MI in low risk precision pathway,

290
00:12:47.745 --> 00:12:50.645
um, and only one death in one mi in the low risk kind

291
00:12:50.645 --> 00:12:51.965
of traditional testing arm.

292
00:12:52.745 --> 00:12:55.125
So very low clinical event rates in this group.

293
00:12:55.665 --> 00:12:58.405
And when we looked at a**l symptoms over the course

294
00:12:58.405 --> 00:13:00.565
of the study, there was no difference, um,

295
00:13:00.565 --> 00:13:02.885
between low risk precision pathway patients

296
00:13:02.885 --> 00:13:05.005
and low risk traditional testing patients.

297
00:13:05.305 --> 00:13:06.405
You know, I think that this shows

298
00:13:06.405 --> 00:13:10.205
that their chest pain got kind of a little bit better,

299
00:13:10.265 --> 00:13:12.765
but didn't do, wasn't different between arms,

300
00:13:12.765 --> 00:13:14.165
whether they were tested or not,

301
00:13:14.165 --> 00:13:16.525
which I think is really important to remember clinically.

302
00:13:16.985 --> 00:13:19.485
And then there was likewise no difference in overall status

303
00:13:19.655 --> 00:13:21.925
based on like quality of life surveys and things.

304
00:13:22.815 --> 00:13:27.035
So I think that this particular result, um, even, even

305
00:13:27.055 --> 00:13:29.915
beyond what we're learning about coronary CT, is that some

306
00:13:29.915 --> 00:13:32.835
of these low risk patients that present with angina maybe,

307
00:13:32.885 --> 00:13:35.075
maybe don't even need to be tested right away.

308
00:13:35.615 --> 00:13:38.195
Um, and I think that the result from the precise trial gives

309
00:13:38.195 --> 00:13:42.155
us some, some reassurance to, to do so to hold off, um, if,

310
00:13:42.175 --> 00:13:46.075
if a patient is truly low risk, um, which is, you know,

311
00:13:46.075 --> 00:13:47.635
important from a healthcare re uh,

312
00:13:47.915 --> 00:13:49.235
resource utilization standpoint.

313
00:13:49.335 --> 00:13:52.395
And I think also offers a little bit of reassurance to the,

314
00:13:52.415 --> 00:13:53.555
um, clinician and,

315
00:13:53.575 --> 00:13:56.515
and to the patient, um, that they don't necessarily be need

316
00:13:56.515 --> 00:13:57.475
to be sheltered right away to

317
00:13:57.475 --> 00:13:58.635
testing if they're very low risk.

318
00:13:59.095 --> 00:14:01.355
So this is the, the prize end result of our case.

319
00:14:01.655 --> 00:14:04.355
So I'll remind you, this was a 52-year-old woman

320
00:14:04.375 --> 00:14:06.195
who presented with dyspnea on exertion.

321
00:14:06.775 --> 00:14:09.515
The left is a representative image of her, uh, c

322
00:14:09.515 --> 00:14:10.835
of her coronary CTA.

323
00:14:11.015 --> 00:14:13.555
Um, the arrow is pointing to the mid LAD

324
00:14:14.015 --> 00:14:16.275
and you can see there's some bright calcium there

325
00:14:16.275 --> 00:14:18.795
that's about a, a moderate stenosis, about 50

326
00:14:18.855 --> 00:14:21.395
to 70% disease in the mid LAD.

327
00:14:21.905 --> 00:14:24.435
This was sent for FFR ct, um,

328
00:14:24.485 --> 00:14:26.035
which is the result on the right.

329
00:14:26.695 --> 00:14:29.075
And you can see that where the blue turns to yellow,

330
00:14:29.265 --> 00:14:32.635
there's a kind of borderline positive oh 0.78,

331
00:14:32.635 --> 00:14:35.875
just under the 0.8 cutoff in corresponding to

332
00:14:35.875 --> 00:14:37.355
that particular, uh, lesion

333
00:14:38.185 --> 00:14:40.555
because she had single vessel disease.

334
00:14:40.655 --> 00:14:44.675
Um, she was managed medically with an aspirin, a statin, um,

335
00:14:44.735 --> 00:14:46.235
and a little dose of beta blocker.

336
00:14:46.255 --> 00:14:47.755
Um, and she's actually done very well.

337
00:14:48.295 --> 00:14:50.955
So in summary, um, I would say that the, uh,

338
00:14:51.115 --> 00:14:55.765
precise trial showed us a lot about the role of coronary ct,

339
00:14:56.185 --> 00:14:57.765
um, in terms of processes care

340
00:14:57.785 --> 00:15:00.325
and the workup of, uh, stable angina.

341
00:15:00.885 --> 00:15:03.885
I think we learned that there's less frequent need for,

342
00:15:03.905 --> 00:15:04.965
um, non-invasive testing.

343
00:15:05.395 --> 00:15:08.765
There's more higher catheterization yields, sort

344
00:15:08.765 --> 00:15:10.925
of getting the, the right people into the cath lab.

345
00:15:11.235 --> 00:15:13.045
There's better use of preventive therapy

346
00:15:13.185 --> 00:15:14.485
and anti-platelet agents

347
00:15:14.985 --> 00:15:16.765
and low risk patients, um,

348
00:15:16.945 --> 00:15:18.485
may not need to be tested right away.

349
00:15:19.055 --> 00:15:20.055
Thank you.

350
00:15:20.655 --> 00:15:21.765
Great. Thank you very much.

351
00:15:21.905 --> 00:15:22.925
Uh, Michelle, before,

352
00:15:22.925 --> 00:15:25.845
before we open it up to more broadly for, um, questions,

353
00:15:25.865 --> 00:15:28.085
let me ask, uh, an initial question.

354
00:15:28.825 --> 00:15:30.965
You know, here, here in the United States, it,

355
00:15:31.025 --> 00:15:34.045
it really is the CCTA has been elevated to,

356
00:15:34.105 --> 00:15:37.445
to this level in recommendation only relatively recently.

357
00:15:37.505 --> 00:15:39.965
So one of, one of the issues in a clinical trial like this

358
00:15:40.545 --> 00:15:41.885
is its generalizability.

359
00:15:42.065 --> 00:15:43.805
Can you comment for a moment, um, for this,

360
00:15:43.865 --> 00:15:46.685
for the broader audience here about the availability,

361
00:15:46.825 --> 00:15:49.085
not just the CC CCTA,

362
00:15:49.105 --> 00:15:50.765
but of the FFR component,

363
00:15:50.765 --> 00:15:53.245
that was such an important part of the precise trial.

364
00:15:54.155 --> 00:15:57.165
Yeah. Um, well, speaking to generalizability, you know,

365
00:15:57.165 --> 00:16:00.205
I'll say that this is, this is much like our case kind

366
00:16:00.205 --> 00:16:02.725
of represents, this is kind of a typical like outpatient,

367
00:16:02.905 --> 00:16:04.245
um, patient that you would get.

368
00:16:04.825 --> 00:16:07.885
Um, and I think precise tried to be sort of pragmatic in

369
00:16:07.885 --> 00:16:10.165
that way to kind of capture these folks to get,

370
00:16:10.305 --> 00:16:13.205
get the people that the results are most generalizable for.

371
00:16:14.225 --> 00:16:16.685
Um, you know, I think that, um, I think

372
00:16:16.685 --> 00:16:19.765
that Precise showed us that coronary CTA with FFR

373
00:16:20.285 --> 00:16:22.805
selective use of FFR when it's appropriate, um,

374
00:16:23.145 --> 00:16:24.365
can be pretty useful.

375
00:16:25.025 --> 00:16:27.725
Um, and so I think that, um, access to

376
00:16:27.725 --> 00:16:28.765
that test is important.

377
00:16:29.345 --> 00:16:33.475
Um, and I think that, um, being able to,

378
00:16:33.695 --> 00:16:36.515
to refer these patients for that particular test seemed

379
00:16:36.515 --> 00:16:38.795
to be better from a process of care standpoint and precise.

380
00:16:39.175 --> 00:16:41.115
That's great. Thank you very much.

381
00:16:41.295 --> 00:16:45.275
So let's, um, let's move on now from a randomized trial

382
00:16:45.705 --> 00:16:47.715
pragmatic effectiveness experience

383
00:16:48.095 --> 00:16:50.555
to a very large real world experience.

384
00:16:50.615 --> 00:16:54.555
And I'll introduce our, uh, next speaker. Um, who's Dr.

385
00:16:54.695 --> 00:16:57.635
Tim Fairburn, a consultant cardiologist at Liverpool Heart

386
00:16:57.635 --> 00:17:01.155
and Chest Hospital, and an honorary senior lecturer lecturer

387
00:17:01.155 --> 00:17:04.355
at the University of Liverpool who will talk to us about

388
00:17:04.955 --> 00:17:06.635
a tr uh, study with one

389
00:17:06.635 --> 00:17:08.795
of the best names I have ever heard the fish

390
00:17:08.795 --> 00:17:11.475
and chips study. Tim, take it away.

391
00:17:12.455 --> 00:17:14.235
Thanks, James. Uh, yeah, it's a very British,

392
00:17:14.455 --> 00:17:15.475
um, study, isn't it?

393
00:17:15.475 --> 00:17:17.475
With a very British name. So nice to meet you all.

394
00:17:17.495 --> 00:17:19.155
I'm Tim Fair, but I'm familiar with all, uh,

395
00:17:19.155 --> 00:17:20.315
in the northwest of England.

396
00:17:20.495 --> 00:17:23.515
Uh, uh, I'm gonna talk to you as, uh, James says about, uh,

397
00:17:23.655 --> 00:17:24.915
my trial fish and CHIPS trial.

398
00:17:24.915 --> 00:17:26.635
But I thought just, uh, on World Heart Day,

399
00:17:26.635 --> 00:17:29.195
we should probably reference back to why we're here today.

400
00:17:29.375 --> 00:17:30.795
And key to really all

401
00:17:30.795 --> 00:17:32.395
of this is the burden of heart disease.

402
00:17:32.455 --> 00:17:34.435
And the, the British Heart Foundation, which is the leading,

403
00:17:34.855 --> 00:17:36.915
uh, charity of heart disease in the uk,

404
00:17:36.915 --> 00:17:40.595
publishes every year some statistics with relation to the,

405
00:17:40.615 --> 00:17:41.835
uh, the burden of heart disease,

406
00:17:41.855 --> 00:17:43.675
not just in the UK but also around the world.

407
00:17:44.055 --> 00:17:46.035
And I thought this from their, uh, from their website,

408
00:17:46.035 --> 00:17:49.965
shows very clearly how important this is in a 620 million

409
00:17:49.965 --> 00:17:52.725
people affected at the current time with heart disease

410
00:17:52.725 --> 00:17:53.845
of one sort or another.

411
00:17:54.345 --> 00:17:56.645
But maybe what's more, uh, astounding is just the number

412
00:17:56.645 --> 00:17:59.165
of people who actually die from heart disease still.

413
00:17:59.305 --> 00:18:01.605
Uh, so 20 million every year, which, which, um,

414
00:18:01.645 --> 00:18:05.325
reflects one in three total deaths around the world, uh, in,

415
00:18:05.465 --> 00:18:06.645
uh, all continents.

416
00:18:06.645 --> 00:18:08.485
So heart disease and coronary heart disease is

417
00:18:08.485 --> 00:18:09.605
really, really very important.

418
00:18:10.585 --> 00:18:12.525
Now, if I bring it back to the uk, I'm sorry,

419
00:18:12.625 --> 00:18:13.965
um, that's where I'm based.

420
00:18:14.025 --> 00:18:16.485
But, uh, uh, they also produce, uh,

421
00:18:16.485 --> 00:18:18.045
some information about the, the local

422
00:18:18.065 --> 00:18:19.765
and regional variation in heart disease.

423
00:18:19.765 --> 00:18:22.125
And this is really a, a map, uh, where the darker colors

424
00:18:22.125 --> 00:18:24.045
of red reflect the greatest disease burden.

425
00:18:24.465 --> 00:18:26.445
And we know I'm, I'm up in this sort of, uh,

426
00:18:26.595 --> 00:18:28.045
left hand side just above Wales.

427
00:18:28.225 --> 00:18:30.685
Uh, and, and certainly in my territory,

428
00:18:30.775 --> 00:18:33.085
heart disease is a major, major, um, issue.

429
00:18:33.305 --> 00:18:35.605
And it is in many different areas of our country.

430
00:18:35.905 --> 00:18:37.405
And we really do need to try and, uh,

431
00:18:37.425 --> 00:18:39.365
and make sure that we're diagnosing these patients

432
00:18:39.365 --> 00:18:40.805
and managing 'em as best we can do.

433
00:18:41.545 --> 00:18:42.925
So that comes onto my trial.

434
00:18:43.385 --> 00:18:46.125
So, uh, we've heard very nicely from Michelle the,

435
00:18:46.145 --> 00:18:49.125
the importance of, uh, using a CT con angiography pathway,

436
00:18:49.585 --> 00:18:52.565
uh, with a potential addition of a CT FFR where appropriate,

437
00:18:52.745 --> 00:18:54.885
uh, help diagnose and manage these patients.

438
00:18:55.505 --> 00:18:58.285
And we know from several trials of which precise is one,

439
00:18:58.285 --> 00:19:01.805
including advance, um, platform, uh, and forecast,

440
00:19:01.865 --> 00:19:04.805
but also from the CT angiography data from particularly

441
00:19:04.815 --> 00:19:08.085
Scott Hart, that, uh, that really these tests are, are,

442
00:19:08.185 --> 00:19:10.445
are very helpful in terms of diagnosing patients

443
00:19:10.465 --> 00:19:11.645
and the management strategies

444
00:19:11.645 --> 00:19:13.485
by changing medications can improve outcomes.

445
00:19:13.905 --> 00:19:16.285
And that's why as James set out at the offset, uh, uh,

446
00:19:16.285 --> 00:19:19.045
they're reflected now in the current guidance in the SE NICE

447
00:19:19.105 --> 00:19:21.205
for the UK and the American Heart

448
00:19:21.465 --> 00:19:23.965
and American College of Cardiology guidance as well.

449
00:19:25.235 --> 00:19:26.815
But what we don't really know is, uh,

450
00:19:26.915 --> 00:19:29.735
if you add in A-C-T-F-F-R to a national program

451
00:19:29.795 --> 00:19:31.095
of CT cardio angiography,

452
00:19:31.445 --> 00:19:33.535
does it really make a real difference in the real world?

453
00:19:34.085 --> 00:19:36.375
This has to be seen in the context in the UK of data

454
00:19:36.375 --> 00:19:38.695
that my colleague, that Wema call has published recently,

455
00:19:39.035 --> 00:19:41.495
um, whereby he looked at the impact of, uh, the,

456
00:19:41.515 --> 00:19:43.455
the NICE guidance recommending CT

457
00:19:43.455 --> 00:19:44.815
angiography as a first line use.

458
00:19:45.115 --> 00:19:47.935
And they found that what maybe was unsurprising was the fact

459
00:19:47.935 --> 00:19:49.775
that, uh, uh, CT angiography goes up.

460
00:19:49.955 --> 00:19:51.695
But what was quite astounding was that they showed

461
00:19:51.695 --> 00:19:53.055
that there was a potential association

462
00:19:53.055 --> 00:19:55.015
between CT angiography growth

463
00:19:55.035 --> 00:19:56.335
and a reduction in cardiovascular

464
00:19:56.635 --> 00:19:58.455
and CHO artery disease deaths.

465
00:19:59.985 --> 00:20:02.965
So we, having set the scene, uh, with the fish

466
00:20:02.965 --> 00:20:05.045
and CHIPS trial, really wanted to look at a national level

467
00:20:05.545 --> 00:20:08.125
at the impact of adding in the CT FFR program

468
00:20:08.225 --> 00:20:10.165
to a CT angiography first pathway.

469
00:20:11.455 --> 00:20:14.395
So NICE is the, uh, clinical body, uh, in the uk,

470
00:20:14.395 --> 00:20:17.635
which makes an independent advisor, uh, as to what sort of,

471
00:20:17.655 --> 00:20:19.555
uh, pathways which we cover, um,

472
00:20:19.725 --> 00:20:21.035
doing for managing patients.

473
00:20:21.265 --> 00:20:22.475
They cover medications,

474
00:20:22.475 --> 00:20:23.875
but they also cover health technologies

475
00:20:23.935 --> 00:20:25.475
and just general clinical guidelines.

476
00:20:25.975 --> 00:20:28.995
And they advocated CT N as the first line test for patients

477
00:20:28.995 --> 00:20:32.355
with, uh, suspected Corona disease very early back in 2016,

478
00:20:32.695 --> 00:20:34.115
so much earlier than the 2019

479
00:20:34.175 --> 00:20:37.515
or 20, uh, 21, uh, uh, guidance from the US and Europe.

480
00:20:38.255 --> 00:20:41.115
And, uh, they also were quite early in recommending the

481
00:20:41.395 --> 00:20:44.435
addition of a CT FFR as a second line test on

482
00:20:44.435 --> 00:20:46.955
that CT angiography where clinically appropriate.

483
00:20:47.150 --> 00:20:49.245
And they made this guidance since, uh, 2017,

484
00:20:50.065 --> 00:20:52.525
but by 2018, so a whole year later, uh,

485
00:20:52.525 --> 00:20:55.205
when they looked back at this, uh, NHS England, uh, saw

486
00:20:55.205 --> 00:20:57.565
that, uh, despite the nice guidance with regards

487
00:20:57.565 --> 00:20:59.205
to the addition of the C-T-F-F-R

488
00:20:59.505 --> 00:21:01.645
and the great usage of CT Corona angiography,

489
00:21:01.645 --> 00:21:04.805
unfortunately no site in the United Kingdoms actually

490
00:21:04.805 --> 00:21:07.445
clinically using the C-T-F-F-R partly due

491
00:21:07.445 --> 00:21:09.165
to commissioning issues and funding issues.

492
00:21:09.505 --> 00:21:10.925
So they said, right, we're gonna take

493
00:21:10.925 --> 00:21:12.005
the decision outta your hands.

494
00:21:12.065 --> 00:21:14.285
We think that this is gonna be beneficial for the patients,

495
00:21:14.285 --> 00:21:16.645
and we want you to use it, so we're gonna fund you

496
00:21:16.645 --> 00:21:17.685
to use it centrally.

497
00:21:18.265 --> 00:21:20.765
So, uh, they, uh, decided to do this from a time period

498
00:21:20.765 --> 00:21:22.205
of 2018 to 2020.

499
00:21:22.945 --> 00:21:25.405
And what we wanted to look at with this study was really how

500
00:21:25.405 --> 00:21:26.925
that impacted patient outcomes.

501
00:21:27.305 --> 00:21:30.605
So we looked at, um, two year follow-up data, so at 90 days,

502
00:21:30.605 --> 00:21:32.365
one year and two years, and we wanted

503
00:21:32.365 --> 00:21:33.685
to look in three different areas.

504
00:21:33.865 --> 00:21:36.245
So first of all, how does it impact the patient's clinical

505
00:21:36.445 --> 00:21:38.565
outcomes so that, um, uh, uh, the likelihood

506
00:21:38.565 --> 00:21:40.525
of having a heart attack or dying from heart attack.

507
00:21:41.085 --> 00:21:43.725
Secondly, how does it impact, uh, the likelihood

508
00:21:43.725 --> 00:21:46.205
of having a another test, uh, further down the line.

509
00:21:46.505 --> 00:21:48.565
So this, uh, is particularly focusing on invasive cardio

510
00:21:48.565 --> 00:21:51.125
angiography, but also all form of cardiovascular tests.

511
00:21:51.545 --> 00:21:52.925
And then thirdly, we wanted to see

512
00:21:52.925 --> 00:21:54.485
how this impacted total healthcare

513
00:21:54.495 --> 00:21:55.805
costs for the healthcare system.

514
00:21:57.395 --> 00:21:59.215
So what we did is we asked, um, uh, uh,

515
00:21:59.215 --> 00:22:02.815
25 different hospital sites, um, who were, uh, part of this,

516
00:22:02.875 --> 00:22:05.935
uh, ITP program from NHS England using the health

517
00:22:05.935 --> 00:22:07.295
technology C-T-F-F-R.

518
00:22:07.635 --> 00:22:10.495
And we asked 'em to send us all of their CT scans, uh, that,

519
00:22:10.595 --> 00:22:11.855
uh, uh, patient data that

520
00:22:11.915 --> 00:22:15.015
who had had a CT scan in their hospitals over the three year

521
00:22:15.015 --> 00:22:16.935
time period from 2017 to 2020.

522
00:22:17.675 --> 00:22:18.895
And we then found that, um,

523
00:22:18.895 --> 00:22:21.495
health outcomes data from a routinely collected, uh,

524
00:22:21.615 --> 00:22:25.135
NHS England's healthcare databases using hospital admission

525
00:22:25.295 --> 00:22:27.855
episodes, so emergency room outpatients,

526
00:22:27.855 --> 00:22:29.175
inpatient, and critical care.

527
00:22:29.625 --> 00:22:31.495
We've got medicines data from something called the

528
00:22:31.615 --> 00:22:32.695
Prescribing Business Authority.

529
00:22:32.995 --> 00:22:34.575
And we've got mortality data from the Office

530
00:22:34.575 --> 00:22:35.655
of National Statistics.

531
00:22:37.245 --> 00:22:38.905
So this is a map of, um, England.

532
00:22:38.975 --> 00:22:42.225
It's, uh, covers, uh, all the health boards, uh, in, uh,

533
00:22:42.525 --> 00:22:44.225
the, uh, uh, country of England.

534
00:22:44.485 --> 00:22:47.505
And as I mentioned, we covered, uh, now 25 different trusts,

535
00:22:47.505 --> 00:22:49.305
but that was actually 27 hospitals.

536
00:22:49.645 --> 00:22:52.305
And this was over half of all of NHS England

537
00:22:52.305 --> 00:22:54.225
and covers 23 different healthcare boards.

538
00:22:54.525 --> 00:22:56.065
And that a list of the hospitals and the, uh,

539
00:22:56.065 --> 00:22:58.425
and the patients that they provided, uh, are in the table.

540
00:22:58.765 --> 00:23:00.705
But essentially what's important to note is

541
00:23:00.705 --> 00:23:02.065
that this is a real mixture.

542
00:23:02.065 --> 00:23:04.905
It's a real geographical mixture from rural to, um, uh,

543
00:23:04.905 --> 00:23:07.705
cities from large teaching, um, hospitals

544
00:23:07.705 --> 00:23:09.145
and university hospitals to smaller,

545
00:23:09.145 --> 00:23:10.505
what we call district general hospitals.

546
00:23:10.605 --> 00:23:11.745
So it's a true representation

547
00:23:11.805 --> 00:23:15.665
of real world clinical practice in, uh, healthcare system.

548
00:23:17.755 --> 00:23:21.045
What we had to do is we had to, um, uh, base, uh, the, uh,

549
00:23:21.405 --> 00:23:23.685
introduction of the technology at what we call a time zero,

550
00:23:24.145 --> 00:23:27.045
so that this is a, a map simply showing the onboarding of,

551
00:23:27.045 --> 00:23:29.005
uh, the different sites or the different hospitals as

552
00:23:29.005 --> 00:23:30.205
to when they started using the health

553
00:23:30.205 --> 00:23:31.405
technology in their practice.

554
00:23:31.825 --> 00:23:34.725
And what we, uh, did is we said that, uh, we're gonna say

555
00:23:34.725 --> 00:23:36.645
that all patients, uh, when the, um,

556
00:23:36.645 --> 00:23:39.685
when the site had the C-T-F-F-R available was day zero,

557
00:23:39.705 --> 00:23:42.445
and everybody who had their tests before that time, uh, was

558
00:23:42.445 --> 00:23:44.485
before the C-T-F-F-R technology was available.

559
00:23:44.665 --> 00:23:46.805
And everybody afterwards was, um, had their scan

560
00:23:46.805 --> 00:23:48.765
during the time that the test was available

561
00:23:48.785 --> 00:23:49.805
as a second line test.

562
00:23:51.355 --> 00:23:53.175
And what we got back from NHS digital

563
00:23:53.275 --> 00:23:54.455
was a lot of information.

564
00:23:54.955 --> 00:23:56.535
So, uh, I'll come into the, uh,

565
00:23:56.535 --> 00:23:58.935
the bit about the 90,533 patients,

566
00:23:58.935 --> 00:24:01.775
but essentially we got 4.7 million health records returned,

567
00:24:01.985 --> 00:24:04.855
which covered, uh, uh, almost 5,000 deaths,

568
00:24:05.165 --> 00:24:07.855
480,000 hospital admissions during the time period,

569
00:24:08.325 --> 00:24:10.335
over a million different diagnostic tests,

570
00:24:10.705 --> 00:24:13.335
330,000 emergency room attendances,

571
00:24:13.515 --> 00:24:15.655
and 2.8 million outpatient visits.

572
00:24:15.955 --> 00:24:18.135
So we got a lot of information back that we had to filter

573
00:24:18.135 --> 00:24:21.815
through and analyze This, uh, covers the, uh, the, uh,

574
00:24:21.815 --> 00:24:23.295
patient population that looked at.

575
00:24:23.355 --> 00:24:27.735
So, uh, the sites returned, uh, back 102,616,

576
00:24:28.235 --> 00:24:30.135
uh, patients who'd had CT scans

577
00:24:30.135 --> 00:24:32.295
during the three year time period between 2017

578
00:24:32.295 --> 00:24:36.255
and 2020, we were un uh, unable to identify very,

579
00:24:36.255 --> 00:24:37.975
very small percentage nor 0.28%.

580
00:24:38.355 --> 00:24:39.895
So all other patients were accurate.

581
00:24:40.515 --> 00:24:43.295
Uh, 5,600 patients withdrew their consent

582
00:24:43.295 --> 00:24:44.335
to take part in this study.

583
00:24:44.755 --> 00:24:46.695
And we had, uh, 6,100 patients

584
00:24:46.695 --> 00:24:48.655
who had had more than one CT scan during

585
00:24:48.655 --> 00:24:49.775
that three year time period.

586
00:24:50.195 --> 00:24:54.735
So this left us with a total final population of 90,553.

587
00:24:55.395 --> 00:24:57.495
And, uh, you can see that we split this into, uh,

588
00:24:57.495 --> 00:24:58.695
the blue group, which are the patients

589
00:24:58.695 --> 00:24:59.935
who had their CT angiography

590
00:24:59.935 --> 00:25:01.415
before the technology was available.

591
00:25:01.875 --> 00:25:04.615
And the red group, uh, 54,800 patients

592
00:25:04.615 --> 00:25:06.135
who had their CT angiography at the time

593
00:25:06.365 --> 00:25:09.015
that CT FR was available as a second line test.

594
00:25:09.835 --> 00:25:12.495
The table on the right hand side, uh, simply shows these,

595
00:25:12.495 --> 00:25:14.615
uh, uh, different demographics of the patient populations.

596
00:25:15.155 --> 00:25:17.895
And, uh, essentially there are a very representative, uh,

597
00:25:17.895 --> 00:25:19.975
population group that we would be investigating

598
00:25:20.035 --> 00:25:21.615
for possible corona artery disease.

599
00:25:21.915 --> 00:25:24.215
So the average age was between 58 and 59.

600
00:25:24.365 --> 00:25:26.415
There's a small statistical difference between this,

601
00:25:26.415 --> 00:25:27.895
but probably not clinically relevant.

602
00:25:28.115 --> 00:25:30.855
And we had a very good representation of, um, of, uh, uh,

603
00:25:30.925 --> 00:25:32.015
females, uh, sex.

604
00:25:32.035 --> 00:25:35.095
So, uh, 48%, uh, which is, uh, really good

605
00:25:35.255 --> 00:25:36.975
'cause these patients are often underrepresented

606
00:25:37.035 --> 00:25:38.135
in randomized trials.

607
00:25:38.795 --> 00:25:41.175
Uh, and, uh, we had, uh, obviously a high burden

608
00:25:41.195 --> 00:25:42.375
of patients with diabetes.

609
00:25:42.515 --> 00:25:45.615
And, um, histories of, uh, things like stroke, TIA

610
00:25:46.375 --> 00:25:49.315
on the very right hand side, uh, you can see that the green,

611
00:25:49.455 --> 00:25:51.355
uh, column that these are the individuals who went on

612
00:25:51.355 --> 00:25:54.035
to have A-C-T-F-F-R as a second line diagnostic test.

613
00:25:54.455 --> 00:25:59.315
And this was 7,836 patients, which was 14% of the,

614
00:25:59.315 --> 00:26:01.195
um, uh, population in those individuals

615
00:26:01.295 --> 00:26:02.995
who could have had this as a second mind test.

616
00:26:03.055 --> 00:26:04.355
So that's from the red group.

617
00:26:04.975 --> 00:26:07.835
And as you might expect, these patients were slightly older

618
00:26:07.855 --> 00:26:09.835
and had more cardiovascular disease risk factors.

619
00:26:10.095 --> 00:26:11.755
As we know that the patients who have been sent

620
00:26:11.755 --> 00:26:13.675
for the C-T-F-F-R are those individuals

621
00:26:13.675 --> 00:26:16.595
who would've had Corona artery disease on their CT scan.

622
00:26:18.515 --> 00:26:21.415
So this slide shows you the primary outcomes of the trial.

623
00:26:21.915 --> 00:26:24.295
Now, uh, for all of these, um, Kaplan-Meier charts,

624
00:26:24.365 --> 00:26:26.455
it's important to remember that the blue group represent

625
00:26:26.455 --> 00:26:28.295
individuals who had their CT scan prior

626
00:26:28.295 --> 00:26:29.375
to the technology being available.

627
00:26:29.795 --> 00:26:32.015
And the red group represent the, uh, the group

628
00:26:32.115 --> 00:26:33.335
who had their CT scan

629
00:26:33.465 --> 00:26:36.055
after C-T-F-F-R was made available to the hospital.

630
00:26:37.315 --> 00:26:39.335
And the key, um, findings were that we found

631
00:26:39.335 --> 00:26:40.375
that there was a, uh,

632
00:26:40.435 --> 00:26:43.605
an 8% significant reduction in all cause mortality following

633
00:26:43.605 --> 00:26:44.765
the introduction of the technology,

634
00:26:45.365 --> 00:26:47.645
a 14% reduction in cardiovascular death.

635
00:26:48.015 --> 00:26:50.405
There was no difference in heart attack occurrence over

636
00:26:50.405 --> 00:26:51.445
the two year time period.

637
00:26:51.945 --> 00:26:53.725
And invasive corona angiograms, uh,

638
00:26:53.985 --> 00:26:55.765
or total invasive corona angiograms were reduced

639
00:26:55.765 --> 00:26:57.445
by 5% over the two years.

640
00:26:58.105 --> 00:27:01.205
So, uh, it, uh, does appear, uh, that, uh, the introduction,

641
00:27:01.425 --> 00:27:03.725
uh, resulted in significant benefits for these outcomes.

642
00:27:05.035 --> 00:27:06.615
If we look at this in a little bit more detail,

643
00:27:06.615 --> 00:27:07.895
as I mentioned, we, uh,

644
00:27:07.895 --> 00:27:09.815
covered 90 days, one years and two years.

645
00:27:10.205 --> 00:27:12.695
This, uh, shows the outcomes at different time points

646
00:27:12.695 --> 00:27:14.775
with the hazard ratios for the two year time points.

647
00:27:15.075 --> 00:27:16.935
So we looked at mortality in a little bit more detail.

648
00:27:17.195 --> 00:27:18.415
So I've mentioned all cause

649
00:27:18.415 --> 00:27:20.055
and cardiovascular reduced significantly,

650
00:27:20.435 --> 00:27:23.375
but if we look at cardiacs versus specific cardiac mortality

651
00:27:23.675 --> 00:27:25.855
and what we call fatal, uh, myocardial infarction.

652
00:27:25.875 --> 00:27:28.335
So, uh, heart attacks that resulted directly in death,

653
00:27:28.465 --> 00:27:30.015
there was no significant difference

654
00:27:30.015 --> 00:27:32.055
between the two groups at either 90 days,

655
00:27:32.235 --> 00:27:33.295
one year or two years.

656
00:27:33.755 --> 00:27:35.135
We looked at total heart attacks

657
00:27:35.195 --> 00:27:36.935
and also non-fatal heart attacks.

658
00:27:36.955 --> 00:27:38.335
And again, there was no difference

659
00:27:38.375 --> 00:27:40.655
between the groups over the two year time period.

660
00:27:41.275 --> 00:27:43.455
But what we did notice, as I've, uh, mentioned, was

661
00:27:43.455 --> 00:27:45.895
that there was a 5% reduction in VA cardio angiography,

662
00:27:46.275 --> 00:27:49.415
and we also saw an increase in the number of, um,

663
00:27:49.775 --> 00:27:52.575
interventions in the form of PCI that performed by 8%,

664
00:27:52.755 --> 00:27:55.055
and that this resulted in, uh, an improvement

665
00:27:55.055 --> 00:27:57.495
or an increase in the revascularization ratio.

666
00:27:57.755 --> 00:27:59.215
So this is the cath lab efficiency

667
00:27:59.215 --> 00:28:00.415
that James was mentioning earlier.

668
00:28:02.305 --> 00:28:05.365
So, uh, uh, to summarize this, if we look at, uh,

669
00:28:05.565 --> 00:28:07.205
revascularization, so the patients who went on

670
00:28:07.385 --> 00:28:08.565
to have some form of, uh,

671
00:28:08.845 --> 00:28:11.485
revascularization forms the CHO arteries at two years,

672
00:28:11.485 --> 00:28:15.045
there was an 8% increase in PCI revascularization, which is,

673
00:28:15.045 --> 00:28:16.365
uh, uh, quite similar to the data

674
00:28:16.365 --> 00:28:17.765
that Michelle showed you from precise.

675
00:28:17.945 --> 00:28:19.405
But there was no increase, uh,

676
00:28:19.405 --> 00:28:21.805
or difference between the number of patients who went to on

677
00:28:21.805 --> 00:28:23.445
to have a corona artery bypass grafting.

678
00:28:24.495 --> 00:28:27.075
Uh, we also looked at invasive crown coronary angiography,

679
00:28:27.095 --> 00:28:28.835
um, not including revascularization.

680
00:28:29.095 --> 00:28:32.555
So the 5% data I showed you, uh, was patients who, uh,

681
00:28:32.555 --> 00:28:35.395
had an invasive cath, um, uh, for whatever reason

682
00:28:35.415 --> 00:28:37.715
and whether or not they did go on to have revascularization.

683
00:28:37.935 --> 00:28:39.475
But this is just looking at patients who,

684
00:28:39.495 --> 00:28:42.155
who did not have revascularization, which is maybe more

685
00:28:42.155 --> 00:28:43.875
of an important endpoint if you're looking to try

686
00:28:43.875 --> 00:28:45.275
to avoid unnecessary tests.

687
00:28:45.895 --> 00:28:47.595
And you can see, again, the curves start

688
00:28:47.595 --> 00:28:49.275
to diverge quite early at 30 days.

689
00:28:49.275 --> 00:28:50.955
And this is significant at 90 days

690
00:28:51.175 --> 00:28:54.035
for reduction in invasive caths at 90 days.

691
00:28:54.585 --> 00:28:56.515
This, uh, was born out at one year

692
00:28:56.575 --> 00:28:58.155
and persisted at two years as well.

693
00:28:58.455 --> 00:29:02.435
And that this overall represented a 14% reduction in, uh,

694
00:29:02.635 --> 00:29:04.035
invasive corona angiograms, uh,

695
00:29:04.035 --> 00:29:06.315
which did not go on in have revascularization.

696
00:29:06.375 --> 00:29:07.595
So even more of a reduction.

697
00:29:08.455 --> 00:29:10.595
We didn't just want to look at invasive corona angiograms.

698
00:29:10.595 --> 00:29:12.395
We wanted to look at all different, uh, forms

699
00:29:12.395 --> 00:29:13.435
of cardiovascular tests.

700
00:29:13.975 --> 00:29:15.955
So this is a, is a, a simple result

701
00:29:16.505 --> 00:29:18.235
showing you the difference of, uh,

702
00:29:18.575 --> 00:29:21.235
all diagnostic tests excluding invasive con angiography.

703
00:29:21.575 --> 00:29:24.235
And you can see that there's a 12% reduction in

704
00:29:24.235 --> 00:29:25.275
all cardiovascular tests.

705
00:29:25.655 --> 00:29:27.715
By two years. In particular, there was a,

706
00:29:27.795 --> 00:29:29.595
a 13% reduction in the likelihood

707
00:29:29.595 --> 00:29:31.475
of having another CT con angiogram.

708
00:29:31.715 --> 00:29:33.235
'cause as we mentioned, 6,000 people did

709
00:29:33.235 --> 00:29:34.395
have a repeat CT scan.

710
00:29:34.925 --> 00:29:37.115
There was a, a dramatic reduction in the number of, uh,

711
00:29:37.115 --> 00:29:38.355
nuclear tests being performed.

712
00:29:38.355 --> 00:29:42.845
So 39% an echocardiography, 48%, there was a small

713
00:29:42.845 --> 00:29:44.725
but statistically significant increase in the number

714
00:29:44.725 --> 00:29:46.125
of patients going cardiac MRI

715
00:29:46.345 --> 00:29:48.125
and also intra coronary procedures.

716
00:29:48.185 --> 00:29:50.365
If the patient did go fa uh, coronary angiogram,

717
00:29:50.545 --> 00:29:52.285
so invasive F ffr, ivus,

718
00:29:52.305 --> 00:29:55.245
and OCT, we then went on to look at the,

719
00:29:55.305 --> 00:29:57.565
at the CT FFR subgroup, uh, themselves,

720
00:29:57.565 --> 00:30:00.445
that's the 7,800 patients who had A-C-T-F-F-R.

721
00:30:00.985 --> 00:30:02.685
And we looked at them in relation

722
00:30:02.685 --> 00:30:03.925
to their C-T-F-F-R results.

723
00:30:03.925 --> 00:30:05.845
So whether or not it was positive or negative,

724
00:30:06.025 --> 00:30:07.365
and the degree of positivity.

725
00:30:07.425 --> 00:30:09.405
So you can see in the bar chart, if we use

726
00:30:09.465 --> 00:30:13.565
nor 0.8 as the cutoff, we have, uh, less than 0.5, uh, 0.51

727
00:30:13.565 --> 00:30:15.205
to 0.7, 0.7, one to 0.8,

728
00:30:15.425 --> 00:30:19.205
and then those that would be considered negative 0.81 to 0.9

729
00:30:19.225 --> 00:30:20.885
and greater than 0.91.

730
00:30:21.345 --> 00:30:23.965
And you can see that might as might be expected, it was, uh,

731
00:30:23.965 --> 00:30:25.485
consistent with third data from advance.

732
00:30:25.825 --> 00:30:28.885
But, uh, the more, uh, uh, positive the CT ffr, the,

733
00:30:28.885 --> 00:30:31.165
or the greater the flow limitation, the more likely

734
00:30:31.165 --> 00:30:32.445
that patients were to go on

735
00:30:32.445 --> 00:30:33.925
and have an invasive corona angiogram

736
00:30:33.925 --> 00:30:35.365
or Reva revascularization.

737
00:30:35.825 --> 00:30:37.845
So you can see 60% ICA

738
00:30:37.985 --> 00:30:41.845
and 57% revascularization in the patients who had a value

739
00:30:41.845 --> 00:30:43.005
of less than oh 0.5.

740
00:30:43.625 --> 00:30:45.485
And importantly, that resulted in a very high

741
00:30:45.725 --> 00:30:48.645
revascularization ratio of 94% in that particular group.

742
00:30:49.025 --> 00:30:51.165
And this was, uh, still high in, uh, in the, um,

743
00:30:51.195 --> 00:30:54.245
gray zone territory between 0.71 and 0.8.

744
00:30:54.665 --> 00:30:56.885
But what was quite interesting that we noted was the fact

745
00:30:56.885 --> 00:30:59.565
that the, despite a very high revascularization ratio,

746
00:30:59.625 --> 00:31:02.245
the real world lower invasive coronary angiogram rates were

747
00:31:02.485 --> 00:31:03.685
probably lower than we'd seen before.

748
00:31:03.865 --> 00:31:05.525
So any 30% in those patients

749
00:31:05.525 --> 00:31:07.445
who had a gray zone territory went on

750
00:31:07.445 --> 00:31:09.045
to have an invasive coronary angiogram.

751
00:31:10.095 --> 00:31:12.435
The capital. My chart on the right hand side simply shows

752
00:31:12.435 --> 00:31:14.955
you the fact that this was some statistically significant,

753
00:31:14.975 --> 00:31:18.315
the likelihood of, uh, a, uh, A-C-D-F-F-R result being able

754
00:31:18.315 --> 00:31:19.515
to predict the patients who gone

755
00:31:19.515 --> 00:31:20.635
and have a revascularization,

756
00:31:20.635 --> 00:31:22.435
particularly in those who had a positive.

757
00:31:22.495 --> 00:31:23.675
So, um, the gray, orange

758
00:31:23.695 --> 00:31:27.035
and blue, uh, uh, curves showing that, uh, uh,

759
00:31:27.035 --> 00:31:29.355
this did predict, uh, patients going on and having a re ask.

760
00:31:30.635 --> 00:31:31.975
We also looked at to see whether

761
00:31:31.975 --> 00:31:33.815
or not it could predict other clinical outcomes.

762
00:31:34.195 --> 00:31:35.775
So this chart shows you the likelihood

763
00:31:35.775 --> 00:31:37.735
of it predicting a myocardial infarcted two years.

764
00:31:38.035 --> 00:31:40.895
And again, it did, um, uh, uh, predict this, uh,

765
00:31:40.895 --> 00:31:43.735
including from the, the gray zone territory up to the, uh,

766
00:31:43.735 --> 00:31:44.815
highest likelihood in those

767
00:31:45.015 --> 00:31:46.055
patients who had the lowest value.

768
00:31:47.525 --> 00:31:49.415
Looking at the CT F of R values in relation

769
00:31:49.415 --> 00:31:50.775
to the other primary outcomes that we looked at,

770
00:31:51.275 --> 00:31:54.655
we could see that, uh, a positive CTFR, um, in the,

771
00:31:54.675 --> 00:31:57.655
the highest range, so less than oh 0.5 did, uh,

772
00:31:57.655 --> 00:32:00.335
predict all cause mortality in cardiovascular death, uh,

773
00:32:00.335 --> 00:32:02.135
between two and three point, uh, uh,

774
00:32:02.235 --> 00:32:03.975
one four increased hazard risk.

775
00:32:04.395 --> 00:32:06.295
And also, as I've mentioned, it did, um,

776
00:32:06.295 --> 00:32:07.495
help predict the likelihood

777
00:32:07.495 --> 00:32:08.855
of having a myocardial infarction.

778
00:32:08.995 --> 00:32:12.455
So between 1.7 and 3.4 increased risk across the range.

779
00:32:13.675 --> 00:32:15.695
So to summarize that, it would appear

780
00:32:15.695 --> 00:32:18.615
that the implementation of A-C-T-F-F-R program at a national

781
00:32:18.615 --> 00:32:20.295
level was associated by two years

782
00:32:20.525 --> 00:32:22.295
with a reduction in all cause death,

783
00:32:22.615 --> 00:32:23.975
a reduction in cardiovascular death,

784
00:32:24.475 --> 00:32:25.855
no difference in heart attack events

785
00:32:25.855 --> 00:32:26.895
for heart attack deaths,

786
00:32:27.195 --> 00:32:30.055
but a reduction in all, uh, downstream cardiovascular tests,

787
00:32:30.055 --> 00:32:31.775
particularly invasive cardio angiography.

788
00:32:32.275 --> 00:32:33.615
And there was an increased, uh,

789
00:32:33.935 --> 00:32:36.415
revascularization in the form of PCI with, uh,

790
00:32:36.535 --> 00:32:38.575
a subsequent improved revascularization ratio

791
00:32:38.575 --> 00:32:41.205
because the number of invasive grande cams were going down.

792
00:32:42.065 --> 00:32:43.605
So, uh, you can see that, uh,

793
00:32:43.605 --> 00:32:45.645
we certainly have answered the first two questions in terms

794
00:32:45.645 --> 00:32:48.565
of, uh, major cardiac events and, uh, downstream tests.

795
00:32:49.025 --> 00:32:51.045
You may, uh, uh, notice I haven't, uh, declined

796
00:32:51.045 --> 00:32:53.205
to you the cost data as we're currently analyzing that now,

797
00:32:53.385 --> 00:32:55.885
and I will, um, be publishing this at a a later time.

798
00:32:56.345 --> 00:32:58.405
So, uh, I'd like to thank you for your attention

799
00:32:58.665 --> 00:33:00.245
and, uh, and James, over to you.

800
00:33:01.285 --> 00:33:03.275
Great. Wow, thank you very much.

801
00:33:03.345 --> 00:33:05.955
It's so interesting to see randomized trial,

802
00:33:06.105 --> 00:33:07.595
pragmatic effectiveness data,

803
00:33:07.655 --> 00:33:10.355
but then very large, uh, real world data, and you

804
00:33:10.355 --> 00:33:12.915
and your colleagues have certainly taken full advantage

805
00:33:12.935 --> 00:33:15.555
of the five or six year headstart you got on the rest

806
00:33:15.555 --> 00:33:18.475
of us from the uk uh, guidelines.

807
00:33:19.055 --> 00:33:21.715
Um, you know, it's always a little tricky to try

808
00:33:21.715 --> 00:33:24.475
and disentangle mechanisms here,

809
00:33:24.575 --> 00:33:27.155
but you know, on on one of your earlier slides,

810
00:33:27.215 --> 00:33:28.235
it was interesting to see

811
00:33:28.235 --> 00:33:30.315
that there was no difference in myocardial infarction

812
00:33:30.315 --> 00:33:32.275
and yet cardiovascular death was lower

813
00:33:32.535 --> 00:33:34.155
and all cause mortality was lower.

814
00:33:34.695 --> 00:33:37.395
How do you think, what, what is downstream from

815
00:33:37.935 --> 00:33:41.955
the te from the test that eventuates in those results,

816
00:33:42.015 --> 00:33:44.755
do you think that is driven, that is associated

817
00:33:44.755 --> 00:33:47.275
with the FFF in, in implementation of FFR?

818
00:33:47.865 --> 00:33:48.995
Yeah, and, and that's something

819
00:33:48.995 --> 00:33:50.235
that we're currently looking at, um,

820
00:33:50.235 --> 00:33:52.435
because as I mentioned, there's a lot of data that we're,

821
00:33:52.435 --> 00:33:54.195
we're filtering through and,

822
00:33:54.215 --> 00:33:55.875
and linking things with associations.

823
00:33:55.935 --> 00:33:57.155
It is difficult with this, um,

824
00:33:57.155 --> 00:33:58.915
observational, um, form of data.

825
00:33:59.375 --> 00:34:01.155
Um, so I mean, the first one is, um,

826
00:34:01.295 --> 00:34:02.635
uh, I suppose medications.

827
00:34:02.975 --> 00:34:04.755
Is there a difference in the usage of medications?

828
00:34:04.755 --> 00:34:06.315
And that's something we're looking at currently now,

829
00:34:06.495 --> 00:34:08.715
you wouldn't expect it to because, um, most of the data,

830
00:34:08.715 --> 00:34:10.795
which Michelle showed as well, is the difference

831
00:34:10.795 --> 00:34:12.275
between having a CT scan

832
00:34:12.315 --> 00:34:13.675
and having a functional test, right?

833
00:34:13.675 --> 00:34:15.435
But all these patients have CT scan,

834
00:34:15.655 --> 00:34:16.995
so we wouldn't necessarily expect there

835
00:34:16.995 --> 00:34:18.195
to be any difference in medications,

836
00:34:18.335 --> 00:34:19.715
but that is something we're looking at.

837
00:34:20.295 --> 00:34:21.315
The next thing is, um,

838
00:34:21.595 --> 00:34:23.435
I suppose the question about the increase in

839
00:34:23.435 --> 00:34:24.515
the revascularizations.

840
00:34:24.735 --> 00:34:26.995
Um, so what we saw was a slight increase in the number

841
00:34:26.995 --> 00:34:30.075
of my infarc that occurred early in the post C-T-F-F-R

842
00:34:30.075 --> 00:34:31.075
group, and that's probably

843
00:34:31.275 --> 00:34:32.315
relation to an increased vascular.

844
00:34:32.455 --> 00:34:33.875
We know that that happens. Mm-hmm.

845
00:34:34.135 --> 00:34:35.915
But then one of the, um, long arguments

846
00:34:35.915 --> 00:34:37.995
that we've been having in cardiology for a long time, uh,

847
00:34:38.015 --> 00:34:39.395
is, um, is, uh, the benefit

848
00:34:39.495 --> 00:34:41.715
or not of revascularization in the form of PCI

849
00:34:41.975 --> 00:34:43.515
and whether that does occur later on

850
00:34:43.515 --> 00:34:45.395
because we only started to see a benefit really at the two

851
00:34:45.395 --> 00:34:47.475
year time point, not at any of the other time points.

852
00:34:47.935 --> 00:34:49.595
So could there be a potential benefit

853
00:34:49.735 --> 00:34:52.475
for patients identifying the high risk patients, um,

854
00:34:52.475 --> 00:34:54.075
and that they get a longer term benefit?

855
00:34:54.295 --> 00:34:56.115
And that's certainly something we'll be aiming

856
00:34:56.115 --> 00:34:58.075
to look at at longer term data in terms of five

857
00:34:58.075 --> 00:35:00.315
and 10 year, um, follow up for these patients.

858
00:35:00.775 --> 00:35:02.235
Um, that's another possibility.

859
00:35:02.535 --> 00:35:04.515
Um, but I think there are, uh, part of the problems

860
00:35:04.515 --> 00:35:06.155
with doing this kind of analysis is that, uh,

861
00:35:06.155 --> 00:35:08.195
you often are left with many questions

862
00:35:08.195 --> 00:35:09.995
or more questions at the end of it than at the beginning.

863
00:35:10.375 --> 00:35:12.555
Um, but uh, yeah, without, without doubt,

864
00:35:12.555 --> 00:35:14.955
it shows some fascinating insights into the sort

865
00:35:14.955 --> 00:35:17.195
of the real world introduction of this kind of, um, uh,

866
00:35:17.195 --> 00:35:19.515
health technology, uh, on a national level

867
00:35:19.515 --> 00:35:21.475
because that, that's the uniqueness of this, um,

868
00:35:21.475 --> 00:35:23.475
of this data, um, and of the NHS

869
00:35:23.475 --> 00:35:25.235
and the fact that they said, no, we want you to use it and

870
00:35:25.235 --> 00:35:26.715
therefore we're gonna pay for you to use it,

871
00:35:26.715 --> 00:35:27.835
which is pretty unique.

872
00:35:28.065 --> 00:35:30.155
That is, that is, and you've taken full advantage.

873
00:35:30.565 --> 00:35:33.395
Thank, thank you both, uh, so very much for some, uh,

874
00:35:33.395 --> 00:35:34.875
wonderful data, and I look forward

875
00:35:34.935 --> 00:35:36.875
to the broader, uh, question period.

876
00:35:37.505 --> 00:35:39.645
And for those of you who are watching this webinar,

877
00:35:39.785 --> 00:35:42.845
please use the question, answer function on Zoom

878
00:35:43.225 --> 00:35:45.445
to type in some questions, and I'll select them.

879
00:35:45.745 --> 00:35:47.365
For Michelle and for Tim,

880
00:35:47.695 --> 00:35:49.405
thank you all very much for joining us.

881
00:35:55.135 --> 00:35:57.765
Hello everybody. We are now, uh, live, uh, with you

882
00:35:57.825 --> 00:35:59.165
for question answers.

883
00:35:59.185 --> 00:36:01.925
Thanks, uh, thanks to so many of you for, um,

884
00:36:02.395 --> 00:36:03.605
sending in questions.

885
00:36:03.825 --> 00:36:05.965
Um, so we, we'll kind of go through things

886
00:36:05.985 --> 00:36:07.965
for about 15 minutes here.

887
00:36:08.185 --> 00:36:13.005
Um, let me start with, um, Michelle, um,

888
00:36:13.145 --> 00:36:15.685
you know, you and your colleagues have, um,

889
00:36:15.755 --> 00:36:17.445
between the PROMISE trial

890
00:36:17.445 --> 00:36:18.965
and the precise trial have done a lot

891
00:36:18.965 --> 00:36:21.565
to advance the science in terms of the evidence available

892
00:36:21.785 --> 00:36:23.445
for, um, ct.

893
00:36:23.905 --> 00:36:26.685
How, how are your programs building awareness, um,

894
00:36:26.945 --> 00:36:29.245
for this approach among stable,

895
00:36:29.505 --> 00:36:32.845
the stable chest pain population, both for cardiology,

896
00:36:32.865 --> 00:36:33.965
but also for primary care?

897
00:36:34.505 --> 00:36:38.525
That's a great question. And also get the important issue

898
00:36:38.525 --> 00:36:40.205
of accessibility of all these tests.

899
00:36:40.945 --> 00:36:43.685
Um, I think that, you know, the result from this trial

900
00:36:43.745 --> 00:36:45.605
and hearing about like both studies

901
00:36:45.605 --> 00:36:48.885
that were presented today does a lot to raise awareness, um,

902
00:36:48.895 --> 00:36:53.165
especially seeing sort of, um, sort of outcomes, um, in,

903
00:36:53.305 --> 00:36:54.805
in a bunch of these studies and,

904
00:36:54.805 --> 00:36:58.005
and understanding the sort of unique utility of these tests.

905
00:36:58.585 --> 00:37:00.405
Um, so I think that that's one piece of it.

906
00:37:00.945 --> 00:37:03.965
Um, and, and disseminating this data has been a big part of,

907
00:37:04.105 --> 00:37:05.885
um, like getting the word out

908
00:37:05.885 --> 00:37:07.085
about the utility of this test.

909
00:37:07.905 --> 00:37:09.685
Thanks. Um, just, and, and Tim

910
00:37:09.745 --> 00:37:12.205
and one of the, one of the folks was asking you,

911
00:37:12.205 --> 00:37:15.885
you may have touched on this in, in the presentation now,

912
00:37:15.905 --> 00:37:19.765
can you just grossly estimate the percent decrease in

913
00:37:19.935 --> 00:37:22.125
diagnostic catheterizations when using

914
00:37:22.765 --> 00:37:26.245
A-C-C-T-A first approach as, as this new standard?

915
00:37:26.835 --> 00:37:28.445
That that's, uh, partly data that

916
00:37:28.465 --> 00:37:30.645
to my colleague Dr. William McCall looked at to, uh,

917
00:37:30.645 --> 00:37:31.805
following the nice guidance.

918
00:37:32.425 --> 00:37:33.525
And in essence,

919
00:37:33.665 --> 00:37:37.205
it rolls out at about 5% year on year reduction in the

920
00:37:37.205 --> 00:37:39.245
number of invasive con angiograms that performed.

921
00:37:39.385 --> 00:37:43.925
So since 20 16, 20 17 in the uk with that nice guidance, um,

922
00:37:44.065 --> 00:37:46.725
uh, that's been a, a steady continual decline.

923
00:37:47.065 --> 00:37:49.805
So we're still doing the same number of acute, um, uh,

924
00:37:50.285 --> 00:37:52.925
procedures, uh, but our diagnostic number

925
00:37:52.925 --> 00:37:55.405
of in vasal can angiograms is going down and down and down,

926
00:37:55.405 --> 00:37:56.645
and that, and that's still going down

927
00:37:56.785 --> 00:37:57.805
as we speak at the moment.

928
00:37:58.065 --> 00:38:00.125
So, um, and that happens to be appropriate.

929
00:38:00.425 --> 00:38:03.285
Um, and it's interesting, when I, when I did a lot of, um,

930
00:38:03.285 --> 00:38:06.325
patient engagement, uh, as part of this, uh, research study,

931
00:38:06.785 --> 00:38:10.405
uh, I was amazed at how, uh, uh, voci were in terms

932
00:38:10.445 --> 00:38:11.485
of their opinions with regards

933
00:38:11.485 --> 00:38:14.485
to avoiding an unnecessary test in particularly an

934
00:38:14.485 --> 00:38:15.805
unnecessary invasive test,

935
00:38:16.035 --> 00:38:18.045
because to me, the being a cardiologist

936
00:38:18.045 --> 00:38:20.125
and invasive, uh, corona angiogram was just a small thing,

937
00:38:20.125 --> 00:38:21.765
but to the patients, it was a massive thing.

938
00:38:21.765 --> 00:38:24.605
Yeah. So, you know, touching upon that, just test, uh, the,

939
00:38:24.605 --> 00:38:26.485
the question to you post, Michelle, it's,

940
00:38:26.485 --> 00:38:28.245
we never really sort of, um, uh,

941
00:38:28.245 --> 00:38:29.485
give the option to the patients.

942
00:38:29.485 --> 00:38:30.685
So certainly in the UK it's just,

943
00:38:30.685 --> 00:38:31.805
here's your test, you're gonna have it.

944
00:38:32.265 --> 00:38:35.085
Um, so you know, it's a, it's a very, very good question

945
00:38:35.265 --> 00:38:37.085
and, uh, it certainly is having a massive

946
00:38:37.105 --> 00:38:38.205
impact. I think the guidance

947
00:38:38.885 --> 00:38:40.725
A along those lines of the

948
00:38:41.365 --> 00:38:43.885
reduction in diagnostic catheterizations, Michelle,

949
00:38:44.305 --> 00:38:47.525
you know, as, as you know, the, the in promise

950
00:38:47.865 --> 00:38:51.285
and in precise, um, unnecessary catheterization

951
00:38:51.345 --> 00:38:55.325
or catheterization without obstructive coronary disease was

952
00:38:55.325 --> 00:38:57.485
used as an endpoint secondary and promise,

953
00:38:57.625 --> 00:38:59.205
and as part of a primary endpoint

954
00:38:59.305 --> 00:39:01.325
and precise, it was a little controversial,

955
00:39:01.545 --> 00:39:05.325
but can you, can you talk about why you incorporated that

956
00:39:05.345 --> 00:39:07.085
and, and the importance, you know, in light of

957
00:39:07.085 --> 00:39:09.965
what Tim just said, of avoiding, um, what

958
00:39:10.605 --> 00:39:12.805
probably is an unnecessary catheterization?

959
00:39:13.635 --> 00:39:15.365
Yeah, that's also a great question.

960
00:39:15.545 --> 00:39:17.165
Um, I would say that, you know, part of

961
00:39:17.165 --> 00:39:19.365
what we were looking at was clinical outcomes and,

962
00:39:19.385 --> 00:39:21.485
and that's important, but we also wanted

963
00:39:21.505 --> 00:39:23.245
to understand process of care

964
00:39:23.505 --> 00:39:25.365
and kind of efficiency of care.

965
00:39:25.465 --> 00:39:26.645
And that's exactly

966
00:39:26.675 --> 00:39:29.925
what the cath without obstructive disease endpoint at that,

967
00:39:30.705 --> 00:39:32.885
um, which I, I think as Tim just mentioned,

968
00:39:32.905 --> 00:39:35.645
is also important to patients, not like having

969
00:39:35.665 --> 00:39:39.245
to undergo an un unnecessary invasive test.

970
00:39:39.865 --> 00:39:41.605
Um, I think that that also gets

971
00:39:42.165 --> 00:39:44.485
a little bit the cost saving part of things too.

972
00:39:44.745 --> 00:39:46.725
Um, and resource utilization part of things.

973
00:39:47.065 --> 00:39:49.965
So trying to have both parts, the clinical part

974
00:39:50.065 --> 00:39:53.125
and the sort of efficiency resources part.

975
00:39:53.705 --> 00:39:55.925
Thanks. Um, so here's, here's more

976
00:39:55.925 --> 00:39:58.365
of an operational almost political question.

977
00:39:58.905 --> 00:40:02.965
Um, any suggestions or tips for aligning radiology

978
00:40:03.185 --> 00:40:06.285
and cardiology from A-C-C-T-A perspective?

979
00:40:06.545 --> 00:40:08.685
So always a challenge, data is key,

980
00:40:09.185 --> 00:40:11.525
but, um, how do, how do you work the alignment?

981
00:40:11.705 --> 00:40:13.005
And it might, I'll ask both of you

982
00:40:13.005 --> 00:40:14.365
and then I'll, I'll chime in too

983
00:40:14.645 --> 00:40:17.485
'cause it might be different in the US and, uh, in the uk.

984
00:40:17.545 --> 00:40:20.925
So Michelle, um, how, how does that work where you work?

985
00:40:21.505 --> 00:40:23.285
Uh, the, it's the ultimate question, right?

986
00:40:23.505 --> 00:40:26.805
Um, I think, I think data is important.

987
00:40:27.085 --> 00:40:29.365
I think like collaborative relationships are important.

988
00:40:30.045 --> 00:40:32.685
I think flow of communication also is important

989
00:40:32.865 --> 00:40:35.525
and making sure each side knows what it is

990
00:40:35.525 --> 00:40:37.725
that they're looking for with each individual testing.

991
00:40:37.945 --> 00:40:39.525
So I think that those are the building

992
00:40:39.525 --> 00:40:40.605
blocks of that relationship.

993
00:40:40.625 --> 00:40:41.845
But yes, the ultimate question.

994
00:40:42.715 --> 00:40:44.805
Okay, Tim, and in the uk, how does that work?

995
00:40:45.385 --> 00:40:47.685
Uh, so interesting. Most departments are either radiology

996
00:40:47.705 --> 00:40:50.565
or cardiologist run for, um, cardiac CT and cardiac R

997
00:40:50.565 --> 00:40:53.605
but in ours we run a joint, um, imaging department.

998
00:40:53.605 --> 00:40:55.445
So I, I work closely and actual fact my

999
00:40:55.445 --> 00:40:56.485
office is now in radiology.

1000
00:40:56.585 --> 00:40:58.325
I'm not even sat with the cardiologists anymore.

1001
00:40:58.505 --> 00:41:00.125
So, uh, and it works really well,

1002
00:41:00.125 --> 00:41:03.365
but you have to do, I think, um, common visions, um,

1003
00:41:03.405 --> 00:41:07.205
common education and, um, the reason why we push this model

1004
00:41:07.205 --> 00:41:09.165
so much is I think you get massive benefits.

1005
00:41:09.305 --> 00:41:11.285
You know, the, the cardiologist's input

1006
00:41:11.285 --> 00:41:13.045
to the imaging department, um, in terms

1007
00:41:13.045 --> 00:41:14.765
of a certain perspectives is very helpful.

1008
00:41:14.785 --> 00:41:16.205
And the radiologist's input in other

1009
00:41:16.205 --> 00:41:17.485
aspects is, uh, is very helpful.

1010
00:41:17.745 --> 00:41:20.525
And you get that combined, you get a better outcome.

1011
00:41:20.825 --> 00:41:23.245
But it, it really much is about, um, lack

1012
00:41:23.245 --> 00:41:25.845
of politics working together, good education

1013
00:41:25.845 --> 00:41:27.725
and all having the same kind of vision, but it will.

1014
00:41:28.405 --> 00:41:31.145
Thanks. Um, so I'll comment also.

1015
00:41:31.205 --> 00:41:33.485
So where I work at Tufts, you know, know, we actually,

1016
00:41:33.485 --> 00:41:35.805
we just share it with, um, radiology.

1017
00:41:35.945 --> 00:41:38.925
It works well. You know, if you start off by saying,

1018
00:41:39.065 --> 00:41:41.525
you know, we're all in this together, um, well, you know,

1019
00:41:41.585 --> 00:41:44.645
the, the money shouldn't flow into one bucket totally.

1020
00:41:44.745 --> 00:41:47.245
Or the other, you know, everybody brings things to the table

1021
00:41:47.265 --> 00:41:49.245
and, you know, think about the patients and the program,

1022
00:41:50.145 --> 00:41:53.365
and if you have the right people, um, that's, it works,

1023
00:41:53.505 --> 00:41:56.605
it works well, and it always has, if, if you start out,

1024
00:41:56.985 --> 00:41:58.565
you know, with a sharing attitude.

1025
00:41:59.105 --> 00:42:01.085
So here's a, here's a question from someone

1026
00:42:01.105 --> 00:42:03.925
who is possibly a medical director at a, at a health plan.

1027
00:42:04.225 --> 00:42:08.285
So at a, at a macro level, the health plan management level,

1028
00:42:08.665 --> 00:42:11.165
how can we, in other words, medical directors

1029
00:42:11.165 --> 00:42:13.165
or chief medical officers, uh,

1030
00:42:13.395 --> 00:42:17.005
incorporate these compelling findings into approval criteria

1031
00:42:17.545 --> 00:42:20.885
for CCTA earlier than the current lagging

1032
00:42:21.465 --> 00:42:23.365
health plan management criteria?

1033
00:42:24.065 --> 00:42:25.325
Um, so maybe I'll start with Tim

1034
00:42:25.325 --> 00:42:28.125
and then Michelle also from different sides

1035
00:42:28.125 --> 00:42:29.405
of the pond's perspective.

1036
00:42:30.185 --> 00:42:32.485
Uh, so I have many scars with relation to this

1037
00:42:32.485 --> 00:42:35.845
because, um, I, I was trying to, um, advocate the use

1038
00:42:35.845 --> 00:42:39.085
of CT angiography and CT FFR since about 2016 and,

1039
00:42:39.105 --> 00:42:40.205
and was, uh, uh,

1040
00:42:40.235 --> 00:42:42.365
have been at numerous times called the ELI with regards to this.

1041
00:42:42.365 --> 00:42:43.965
But, uh, you know, in actual fact,

1042
00:42:44.005 --> 00:42:45.205
I think it's not about that.

1043
00:42:45.205 --> 00:42:46.485
It's about the evidence

1044
00:42:46.485 --> 00:42:48.405
and trying to incorporate that into your practice.

1045
00:42:48.465 --> 00:42:50.245
And as you set out, James, there's

1046
00:42:50.265 --> 00:42:52.325
so much high level evidence with regards

1047
00:42:52.325 --> 00:42:54.565
to these two strategies with regards to the diagnosis

1048
00:42:54.565 --> 00:42:57.325
and management of patients that I just think we need to show

1049
00:42:57.325 --> 00:42:59.845
that evidence, show the cost benefit, show the benefit

1050
00:42:59.905 --> 00:43:01.485
to the patient themselves, and then,

1051
00:43:01.745 --> 00:43:04.325
and as long as that education is then aware that there,

1052
00:43:04.325 --> 00:43:06.205
then I don't understand why people wouldn't in,

1053
00:43:06.225 --> 00:43:07.445
um, sort of implement it.

1054
00:43:07.825 --> 00:43:09.365
It did take a bit of time in the uk,

1055
00:43:09.665 --> 00:43:12.165
but the great advantage around the UK was that nice.

1056
00:43:12.385 --> 00:43:15.285
And the NHS actually looked at the events, believed in it,

1057
00:43:15.285 --> 00:43:17.365
and were willing to advocate it on a national level,

1058
00:43:17.425 --> 00:43:18.525
and that makes a big difference.

1059
00:43:18.525 --> 00:43:19.525
You need advocates

1060
00:43:20.825 --> 00:43:21.825
And Mic Michelle.

1061
00:43:21.865 --> 00:43:23.725
Um, just your comments on this,

1062
00:43:23.745 --> 00:43:26.885
but just to say, you know, in the US of course, you know,

1063
00:43:26.885 --> 00:43:29.125
guide, guide, you know, a few years behind the uk,

1064
00:43:29.145 --> 00:43:31.405
but guidelines have now moved CCTA,

1065
00:43:31.465 --> 00:43:34.205
so the professional societies are certainly, um,

1066
00:43:34.845 --> 00:43:35.885
recognizing this, but how,

1067
00:43:35.945 --> 00:43:38.485
how would you in incorporate this into health

1068
00:43:38.515 --> 00:43:39.725
plan management criteria?

1069
00:43:40.685 --> 00:43:43.455
Yeah, this is a, it feels like a pertinent question.

1070
00:43:43.515 --> 00:43:45.655
It was just last week I was on the phone trying

1071
00:43:45.655 --> 00:43:47.215
to get a coronary CP approved.

1072
00:43:47.395 --> 00:43:50.615
Um, I would say that the data is really helpful, um,

1073
00:43:50.795 --> 00:43:54.295
and even, even in that context, like fighting the data

1074
00:43:54.475 --> 00:43:55.775
of CTA benefit

1075
00:43:55.955 --> 00:43:58.255
and particular benefit in young women, um,

1076
00:43:58.255 --> 00:44:00.055
which is often the case in my patient panel.

1077
00:44:00.595 --> 00:44:02.175
Um, those kind

1078
00:44:02.175 --> 00:44:03.575
of things I think insurance

1079
00:44:03.815 --> 00:44:04.855
companies have been receptive to.

1080
00:44:04.995 --> 00:44:08.975
And so I think, um, getting education out about the data

1081
00:44:08.975 --> 00:44:10.095
that's available and,

1082
00:44:10.115 --> 00:44:11.775
and the potential benefits that it has,

1083
00:44:11.975 --> 00:44:13.015
I think, I think is helpful.

1084
00:44:13.955 --> 00:44:15.705
Great. Go ahead.

1085
00:44:15.765 --> 00:44:19.385
Uh, my analogy with this often is with regards to if, um,

1086
00:44:19.645 --> 00:44:21.985
uh, with this regards to the Scott Hart trial

1087
00:44:21.985 --> 00:44:25.665
and a 50% reduction in heart attacks, if that was a, a stent

1088
00:44:25.885 --> 00:44:26.905
or a product

1089
00:44:27.005 --> 00:44:28.785
or farm product, rather than just getting a test done

1090
00:44:29.005 --> 00:44:32.325
and it had a similar reduction hazard of 50%, you know,

1091
00:44:32.325 --> 00:44:35.325
it would be world headline news, it'd be the best seller

1092
00:44:35.325 --> 00:44:37.605
around everybody would be able to pay thousands.

1093
00:44:37.605 --> 00:44:38.725
That wouldn't, don't forget,

1094
00:44:38.725 --> 00:44:39.925
forget the quallies, it doesn't matter.

1095
00:44:39.925 --> 00:44:40.965
We'll just pay for it. But

1096
00:44:40.965 --> 00:44:43.325
because it's a test for some reason, it doesn't seem to have

1097
00:44:43.325 --> 00:44:44.645
that impact, and yet it should do.

1098
00:44:44.645 --> 00:44:46.565
It's a, you know, it's a massive outcome trial that,

1099
00:44:47.155 --> 00:44:49.885
Yeah, and I think, you know, at this point, you know, in,

1100
00:44:49.905 --> 00:44:52.005
in the past the, you know,

1101
00:44:52.005 --> 00:44:54.485
the pushback from payers was always, you know,

1102
00:44:54.485 --> 00:44:55.565
there wasn't a lot of evidence.

1103
00:44:55.635 --> 00:44:56.685
It's all observational.

1104
00:44:57.385 --> 00:45:01.685
But you know, the, the level of evidence in both the,

1105
00:45:01.985 --> 00:45:04.165
you know, ra, randomized clinical trial,

1106
00:45:04.165 --> 00:45:05.325
randomized controlled trials

1107
00:45:05.505 --> 00:45:09.165
and monstrous big data is now PR pretty overwhelming.

1108
00:45:09.825 --> 00:45:13.245
Tim, where does, where does coronary calcium fit

1109
00:45:13.355 --> 00:45:14.365
into to all of this?

1110
00:45:14.385 --> 00:45:17.045
You know, in the, and some have advocated in the past to use

1111
00:45:17.565 --> 00:45:20.125
coronary calcium as kind of a screening test

1112
00:45:20.265 --> 00:45:24.405
before doing other stress tests or a full CT angiogram.

1113
00:45:25.225 --> 00:45:27.725
So I, I'll have to declare, I'm an outlier in this.

1114
00:45:27.845 --> 00:45:30.485
I haven't been doing a calcium score in my chest pain

1115
00:45:30.765 --> 00:45:32.285
patients for I think the last 10 years

1116
00:45:32.285 --> 00:45:33.405
because I didn't see the point

1117
00:45:33.405 --> 00:45:34.845
as it were to change what I was gonna do.

1118
00:45:35.265 --> 00:45:37.605
Um, but so I mean, I think in the patients

1119
00:45:37.605 --> 00:45:39.365
who are clearly symptomatic, the reason

1120
00:45:39.365 --> 00:45:41.925
for doing a calcium score for me is not to, if it's high

1121
00:45:41.925 --> 00:45:44.405
to stop and not go ahead nor to diagnose,

1122
00:45:44.405 --> 00:45:46.125
because you, if the, particularly we've got younger

1123
00:45:46.125 --> 00:45:49.045
population, I, it, it's probably more about trying

1124
00:45:49.045 --> 00:45:50.885
to ban your acquisition to get the best images

1125
00:45:50.945 --> 00:45:52.045
for your CT angiogram.

1126
00:45:52.045 --> 00:45:54.005
So if there's a lot of calcium, you might go for 120.

1127
00:45:54.005 --> 00:45:55.645
So it is more technical factors for me.

1128
00:45:56.585 --> 00:45:58.485
That's not to say that calcium scoring in terms

1129
00:45:58.485 --> 00:46:01.165
of calcium burden isn't a good risk predictor in terms

1130
00:46:01.165 --> 00:46:02.285
of having future events.

1131
00:46:02.585 --> 00:46:04.925
But the question for the majority of patients who have been

1132
00:46:04.925 --> 00:46:05.925
for a CT corona angiogram

1133
00:46:06.065 --> 00:46:08.045
for my practice is patients with chest pain.

1134
00:46:08.145 --> 00:46:09.365
And in those patients, you want

1135
00:46:09.365 --> 00:46:10.445
to know whether they have disease

1136
00:46:10.505 --> 00:46:11.765
and whether it's obstructive or not.

1137
00:46:11.765 --> 00:46:14.645
Mm-hmm. And doesn't actually always tell you that.

1138
00:46:14.945 --> 00:46:16.725
Um, so that, that, that's my, for me,

1139
00:46:16.725 --> 00:46:18.165
it's not in my standard clinical practice,

1140
00:46:18.225 --> 00:46:21.605
but as I, I am a little bit of an ally, um, in terms of, uh,

1141
00:46:21.625 --> 00:46:23.845
uh, most of my colleagues still do it for the reasons

1142
00:46:23.845 --> 00:46:25.885
that I've explained to you in terms of doing it,

1143
00:46:25.985 --> 00:46:27.965
but they don't tend to do it now in terms of, oh,

1144
00:46:27.965 --> 00:46:29.325
it's too high, let's not go ahead.

1145
00:46:29.465 --> 00:46:31.485
Um, or if it's negative, let's not, go ahead.

1146
00:46:32.515 --> 00:46:35.415
Six. Thank you. Um, you know, Michelle, one

1147
00:46:35.415 --> 00:46:36.975
of the things when, you know, when you're thinking about

1148
00:46:37.255 --> 00:46:40.615
CCTA versus stress testing, you know, with a stress test,

1149
00:46:40.995 --> 00:46:42.535
you know, patient on a treadmill,

1150
00:46:42.535 --> 00:46:45.175
whether you're doing just ECG or imaging, you know,

1151
00:46:45.175 --> 00:46:48.495
and we've grown up all of us being used to, um,

1152
00:46:48.765 --> 00:46:52.015
getting the symptomatic information from the stress test,

1153
00:46:52.015 --> 00:46:53.815
you know, they developed chest pain or they didn't,

1154
00:46:53.815 --> 00:46:56.255
or it was typical of their usual symptoms on a treadmill.

1155
00:46:56.515 --> 00:46:59.775
And of course you miss that with, um, CTA.

1156
00:47:00.195 --> 00:47:01.975
Do, do you find that problematic

1157
00:47:02.035 --> 00:47:04.775
or do all these trials just suggest, yes, you miss that,

1158
00:47:04.795 --> 00:47:06.575
but you end up at the same place anyways?

1159
00:47:07.825 --> 00:47:09.605
Um, I think, I mean, I think you miss it,

1160
00:47:09.605 --> 00:47:10.685
but you get other things,

1161
00:47:10.945 --> 00:47:14.445
and I'll say that FFR giving you like functional information

1162
00:47:14.495 --> 00:47:16.645
gives you like insight into that,

1163
00:47:16.965 --> 00:47:19.125
although, albeit in a slightly different way.

1164
00:47:19.745 --> 00:47:22.565
Um, but I think like while you miss like the moment when

1165
00:47:22.765 --> 00:47:24.725
symptoms develop and, and that piece of data,

1166
00:47:25.145 --> 00:47:27.445
you get all this other data about their exact anatomy

1167
00:47:27.555 --> 00:47:29.885
that guides like your lipid management going forward

1168
00:47:29.985 --> 00:47:32.325
and the whether or not you use aspirin in that person,

1169
00:47:32.335 --> 00:47:35.725
which is actually a, a decision for somebody in a kind

1170
00:47:35.725 --> 00:47:37.325
of quasi primary prevention space.

1171
00:47:37.785 --> 00:47:40.045
But I think that even though you lose that, that piece

1172
00:47:40.045 --> 00:47:43.325
of symptoms, you can replicate a lot of it with FFR, um,

1173
00:47:43.325 --> 00:47:44.445
and you get a lot of other data.

1174
00:47:44.445 --> 00:47:45.445
That's really helpful.

1175
00:47:46.245 --> 00:47:50.475
Great. Thanks. Um, another question is about, um, who,

1176
00:47:51.055 --> 00:47:53.275
who is trained to read CTAs?

1177
00:47:53.275 --> 00:47:56.355
This is interesting. Are interventional cardiologists today

1178
00:47:56.355 --> 00:48:00.075
trained enough or feel expert enough to read

1179
00:48:00.095 --> 00:48:01.755
and interpret CCTs,

1180
00:48:01.775 --> 00:48:03.195
or do you think there's a learning curve?

1181
00:48:03.335 --> 00:48:04.915
So let me ask Tim and then Michelle.

1182
00:48:06.065 --> 00:48:07.445
So the answer to that is there's

1183
00:48:07.445 --> 00:48:08.485
a learning curve without a doubt.

1184
00:48:08.505 --> 00:48:10.285
And I think not just interventional cardiologists,

1185
00:48:10.285 --> 00:48:13.765
general cardiologists, ex surgeons, um, uh, you know,

1186
00:48:13.765 --> 00:48:15.525
and that's, I ran a national conference last week

1187
00:48:15.525 --> 00:48:18.005
and had this focus specifically on it to try to get

1188
00:48:18.005 --> 00:48:19.725
as many interventional cardiologists to come

1189
00:48:19.725 --> 00:48:22.285
because I think it's really important Carlos Col doing a lot

1190
00:48:22.285 --> 00:48:24.365
of work and this integration into the cath lab.

1191
00:48:24.545 --> 00:48:26.405
Um, but I think just generally it's important

1192
00:48:26.705 --> 00:48:29.045
and I'm delighted that in the UK now, um,

1193
00:48:29.045 --> 00:48:30.805
they've just changed it last year, this

1194
00:48:30.865 --> 00:48:33.645
before we ought to be what they call level three trained

1195
00:48:33.645 --> 00:48:34.965
and diagnostic invasive cardio

1196
00:48:34.965 --> 00:48:36.525
angiography, uh, during training.

1197
00:48:36.785 --> 00:48:38.525
Now they've scrapped that and said everybody has

1198
00:48:38.525 --> 00:48:40.165
to be level three in cardiac ct.

1199
00:48:40.195 --> 00:48:41.685
Well, not level three, but level two.

1200
00:48:42.485 --> 00:48:45.865
So, so, you know, in your, your core training for everybody,

1201
00:48:46.085 --> 00:48:47.825
um, uh, who's gonna cardiologist in the UK

1202
00:48:47.825 --> 00:48:50.825
for the future will be involving doing, um, coronary ct.

1203
00:48:51.165 --> 00:48:53.185
So I think that's the way forwards without a doubt.

1204
00:48:53.405 --> 00:48:55.825
Um, um, we've got a bit of way to go,

1205
00:48:55.825 --> 00:48:56.985
but the adoption, the,

1206
00:48:56.985 --> 00:48:58.825
just the change in the last few years

1207
00:48:58.985 --> 00:49:00.105
I think has been enormous.

1208
00:49:00.445 --> 00:49:01.665
And, you know, with the US guidance,

1209
00:49:01.865 --> 00:49:03.585
I feel follow the same pattern soon.

1210
00:49:03.765 --> 00:49:05.385
So we are getting there, but you know,

1211
00:49:05.405 --> 00:49:06.465
it takes a bit of time to,

1212
00:49:08.035 --> 00:49:09.815
And, and, and Michelle, what do you, what do you think

1213
00:49:09.875 --> 00:49:14.415
for a path pathway to CCTA interpretation in the us?

1214
00:49:14.885 --> 00:49:17.655
Yeah, it, I mean, it's, it's separate currently, um,

1215
00:49:17.655 --> 00:49:20.615
from interventional and it's a separate field of study, um,

1216
00:49:20.615 --> 00:49:22.655
that is like a separate certification process.

1217
00:49:23.155 --> 00:49:25.495
Um, and so it takes, takes additional time.

1218
00:49:25.815 --> 00:49:26.935
I, I think it's worthwhile.

1219
00:49:27.115 --> 00:49:28.695
Um, but it's, but it's still separate

1220
00:49:28.715 --> 00:49:30.415
and still separate training pathway at the moment,

1221
00:49:30.835 --> 00:49:32.135
but I, I love that it's integrated.

1222
00:49:32.155 --> 00:49:33.735
That's really cool. Yeah. Yeah.

1223
00:49:39.415 --> 00:49:40.795
Here's another interesting one with,

1224
00:49:40.795 --> 00:49:44.595
with the higher adoption of CCTA anticipated in the future,

1225
00:49:45.455 --> 00:49:47.835
how do you see the potential of use

1226
00:49:47.835 --> 00:49:50.635
of the information from CTA to be used for planning

1227
00:49:50.815 --> 00:49:55.475
and strategizing for pro, for prospectively, for PCIs?

1228
00:49:55.625 --> 00:49:57.155
What information could be helpful

1229
00:49:57.735 --> 00:49:59.435
for strategic PCI planning?

1230
00:49:59.455 --> 00:50:01.395
Let me, maybe I'll ask Tim first, and then Michelle,

1231
00:50:03.055 --> 00:50:04.905
This is one of my favorite topics at the moment.

1232
00:50:05.225 --> 00:50:06.585
I think it's something perfect.

1233
00:50:08.365 --> 00:50:10.185
Um, you know, this is

1234
00:50:10.215 --> 00:50:13.185
what we should be doing now in every report is not just

1235
00:50:13.185 --> 00:50:16.225
telling the interventionalists that, uh, yes it is, uh,

1236
00:50:16.225 --> 00:50:18.665
significant or no, it's not obstructive or non-obstructive,

1237
00:50:18.685 --> 00:50:20.585
but telling 'em a whole raft of information about

1238
00:50:20.585 --> 00:50:23.225
how it can help them plan the PCI, whether it

1239
00:50:23.285 --> 00:50:25.305
or whether even or not, it's likely to be benefit

1240
00:50:25.415 --> 00:50:28.405
because one man's 70%, which is shorter and narrow

1241
00:50:28.405 --> 00:50:31.765
and focal disease may benefit from a PCI and another man's

1242
00:50:31.765 --> 00:50:33.165
or ladies' disease, which is long

1243
00:50:33.165 --> 00:50:35.445
and diffuses not gonna benefit from a PCI.

1244
00:50:35.715 --> 00:50:37.725
There's a, a chap who's trailblazing this,

1245
00:50:37.725 --> 00:50:40.325
Carlos Collet from Ton Belgium, he's done the P three trial.

1246
00:50:40.375 --> 00:50:42.005
We're now taking part in the P four trial,

1247
00:50:42.345 --> 00:50:43.885
and I think once P four, um,

1248
00:50:43.885 --> 00:50:45.565
publishes again in the next few years,

1249
00:50:45.755 --> 00:50:47.005
that that will really change.

1250
00:50:47.215 --> 00:50:49.285
It'll be a paradigm shift in the way that we practice,

1251
00:50:49.305 --> 00:50:52.005
but I think we can and should be providing more information

1252
00:50:52.005 --> 00:50:54.045
at the current time, um, to the intervention.

1253
00:50:55.435 --> 00:50:57.135
Thanks, Michelle. Any comments further?

1254
00:50:57.605 --> 00:50:59.895
Yeah, I, I, um, I practice in prevention,

1255
00:50:59.895 --> 00:51:01.095
so a little bit on the opposite end

1256
00:51:01.095 --> 00:51:02.135
of the interventional spectrum,

1257
00:51:02.515 --> 00:51:05.255
but I'll say, um, from, you know, talking

1258
00:51:05.275 --> 00:51:07.615
to my colleagues when I've sent patients to the cath lab,

1259
00:51:08.035 --> 00:51:10.655
um, I, I think it is helpful to know what you're up against

1260
00:51:10.715 --> 00:51:13.415
and know what degree of disease you're gonna be looking at

1261
00:51:13.435 --> 00:51:14.735
or likely be looking at.

1262
00:51:14.935 --> 00:51:17.335
I think it helps a lot with procedural planning and,

1263
00:51:17.475 --> 00:51:20.095
and maybe even helps the patient too, have a sense of, of

1264
00:51:20.095 --> 00:51:21.655
what they're in for after the cath.

1265
00:51:22.355 --> 00:51:23.655
Um, so I think that that is,

1266
00:51:23.685 --> 00:51:25.015
that is something that's very useful.

1267
00:51:25.915 --> 00:51:27.375
Um, so let me, uh, Michelle,

1268
00:51:27.375 --> 00:51:29.735
this is a little more in the prevention ballpark.

1269
00:51:30.235 --> 00:51:32.735
Um, can you comment on the technologies

1270
00:51:32.795 --> 00:51:36.055
and the use of, of CCT in a distinguished soft plaque,

1271
00:51:36.055 --> 00:51:38.135
heterogeneous plaque, calcified plaque?

1272
00:51:38.515 --> 00:51:40.055
You know, none of that really played too much

1273
00:51:40.055 --> 00:51:42.295
of a role in precise and,

1274
00:51:42.355 --> 00:51:44.735
and probably not in in fish, fish and chips either.

1275
00:51:44.875 --> 00:51:46.775
You know, Scott Hart has put out a lot about that

1276
00:51:46.775 --> 00:51:48.135
and there's the literature's growing.

1277
00:51:48.385 --> 00:51:51.015
Where, where does that stand in terms of using

1278
00:51:51.015 --> 00:51:52.495
that information to drive

1279
00:51:53.215 --> 00:51:55.815
differential prevention strategies, let's say?

1280
00:51:56.365 --> 00:51:59.015
Yeah, I think the technology is evolving a

1281
00:51:59.015 --> 00:52:00.055
lot in this space.

1282
00:52:00.085 --> 00:52:02.735
Like we're getting a lot more information about plaque

1283
00:52:02.735 --> 00:52:05.575
characteristics, and I think that's, that's on the,

1284
00:52:05.875 --> 00:52:08.815
that's increasing exponentially in what we're able to learn.

1285
00:52:09.215 --> 00:52:11.615
I think, you know, we know a lot about high risk plaque

1286
00:52:11.615 --> 00:52:13.455
being associated with worse outcomes.

1287
00:52:13.955 --> 00:52:16.255
Um, and I think, you know, uh, bringing it back

1288
00:52:16.255 --> 00:52:17.615
to the prevention side, I think that

1289
00:52:17.615 --> 00:52:20.575
that can sometimes help us tailor how aggressive we need

1290
00:52:20.575 --> 00:52:22.495
to be when we get these results that are sort

1291
00:52:22.495 --> 00:52:23.655
of non-obstructive disease.

1292
00:52:23.675 --> 00:52:26.335
It helps us kind of understand like how,

1293
00:52:26.435 --> 00:52:28.335
how risky the finding is that we get.

1294
00:52:29.325 --> 00:52:30.895
I'll also add that I think what,

1295
00:52:30.925 --> 00:52:33.935
what we see in literature is just an explosion of, um,

1296
00:52:34.015 --> 00:52:36.815
attempts to incorporate artificial intelligence

1297
00:52:36.815 --> 00:52:41.535
and machine learning into, um, characterizing the plaques

1298
00:52:41.535 --> 00:52:43.135
as opposed to human eyeballs.

1299
00:52:43.215 --> 00:52:46.575
I, I think, you know, it's potentially a really good use of

1300
00:52:46.605 --> 00:52:47.735
that kind of technology.

1301
00:52:49.755 --> 00:52:52.375
Um, next, next question.

1302
00:52:52.595 --> 00:52:56.295
What's the utility of CT plus minus FFR CT

1303
00:52:56.925 --> 00:53:00.815
pathway in higher higher risk patients presenting

1304
00:53:00.815 --> 00:53:04.655
with chest pain, such as those with existing CAD or stents

1305
00:53:04.655 --> 00:53:07.575
or, or even potentially, you know, suspected A CS?

1306
00:53:09.275 --> 00:53:12.375
So, uh, in, in nice we got, uh, in the UK we got rid of,

1307
00:53:12.555 --> 00:53:13.855
uh, risk stratification.

1308
00:53:13.915 --> 00:53:16.735
So we don't categorize low, intermediate or heart.

1309
00:53:16.735 --> 00:53:19.175
Essentially, if they've had coronary artery disease proven

1310
00:53:19.195 --> 00:53:21.215
in the past or previous dental cabbage,

1311
00:53:21.285 --> 00:53:22.735
then they're recommended not to go

1312
00:53:22.735 --> 00:53:23.975
for a CT coronary angiogram.

1313
00:53:23.975 --> 00:53:25.860
So that's about one in four of the population who come

1314
00:53:25.860 --> 00:53:27.125
to a standard chest pain club.

1315
00:53:27.625 --> 00:53:29.165
Um, but for three outta four,

1316
00:53:29.275 --> 00:53:30.645
they don't get risk stratified.

1317
00:53:30.645 --> 00:53:32.485
They all get referred for CT then.

1318
00:53:32.665 --> 00:53:34.365
And initially we were horrified by this,

1319
00:53:34.385 --> 00:53:35.765
but natural fact now doing it,

1320
00:53:36.025 --> 00:53:37.285
it is, it's standard of practice.

1321
00:53:37.285 --> 00:53:39.245
It's not too bad. It's, it's actually okay.

1322
00:53:39.785 --> 00:53:42.045
Um, so, uh, you know, it's amazing.

1323
00:53:42.325 --> 00:53:44.725
C you can provide answers to the majority of these patients,

1324
00:53:45.025 --> 00:53:46.685
the ones where, um, CTFR

1325
00:53:46.685 --> 00:53:48.925
and people ask us often, well, what about the high burden

1326
00:53:48.925 --> 00:53:50.525
of calcium disease, et cetera?

1327
00:53:50.525 --> 00:53:52.685
Does, you know, um, uh, does it impact your use?

1328
00:53:52.745 --> 00:53:55.285
Now, if anything, it can help you in that instance

1329
00:53:55.285 --> 00:53:56.845
because we know the higher the degree of calcium,

1330
00:53:56.945 --> 00:53:59.445
the lower your specificity in your accuracy yourself

1331
00:53:59.445 --> 00:54:02.645
as a reporter, even as an expert, um, goes down.

1332
00:54:02.945 --> 00:54:04.965
And that's where the CTFR makes a, a more

1333
00:54:04.965 --> 00:54:06.405
of an incremental, uh, difference.

1334
00:54:06.405 --> 00:54:08.525
So your accuracy is improved. Yes.

1335
00:54:08.745 --> 00:54:12.045
Uh, the CT FR um, accuracy is again, a little bit reduced

1336
00:54:12.045 --> 00:54:14.245
with the more calcium, but incrementally better

1337
00:54:14.245 --> 00:54:15.365
than your opinion itself.

1338
00:54:15.385 --> 00:54:16.565
So, so for those kind of cases,

1339
00:54:16.685 --> 00:54:18.165
I actually find it very, very useful.

1340
00:54:18.265 --> 00:54:19.645
Um, and it, it's starting

1341
00:54:19.645 --> 00:54:21.685
to give people a little bit more confidence in terms

1342
00:54:21.685 --> 00:54:24.045
of going ahead, you know, and doing a CT congram

1343
00:54:24.045 --> 00:54:26.445
and a 76-year-old who's got a calcium score of a thousand.

1344
00:54:26.865 --> 00:54:29.565
So, you know, in the past my radiology colleagues would sort

1345
00:54:29.565 --> 00:54:31.085
of bulk at that and say, no, definitely not.

1346
00:54:31.085 --> 00:54:32.965
We're not gonna go ahead and give them, give them contrast.

1347
00:54:32.985 --> 00:54:34.165
But now that you finally do,

1348
00:54:34.265 --> 00:54:36.085
and we do get answers and accurate answers too.

1349
00:54:37.575 --> 00:54:40.495
Interesting. Um, Michelle, different, different question.

1350
00:54:40.755 --> 00:54:42.975
Um, you know, in in the UK as you know, the

1351
00:54:43.815 --> 00:54:45.855
C-C-C-T-A is sort of first line,

1352
00:54:45.865 --> 00:54:48.575
everything else is second line in the US we, you know,

1353
00:54:48.575 --> 00:54:49.935
do always have to be a little different.

1354
00:54:49.935 --> 00:54:52.695
And, you know, CCCT has found itself kind

1355
00:54:52.695 --> 00:54:54.735
of on a relatively equivalent playing field

1356
00:54:54.735 --> 00:54:56.255
with the stress imaging modalities,

1357
00:54:56.535 --> 00:54:58.655
although with a level of evidence compared to,

1358
00:54:59.155 --> 00:55:00.615
um, er level of evidence.

1359
00:55:01.435 --> 00:55:04.135
How do you and your, your colleagues decide, you know,

1360
00:55:04.135 --> 00:55:06.975
in a particular patient, you know, in which direction to go,

1361
00:55:06.995 --> 00:55:09.335
who gets CCTA who gets stress testing?

1362
00:55:10.675 --> 00:55:12.805
Depends a lot, I would say on individual

1363
00:55:12.805 --> 00:55:13.845
patient characteristics.

1364
00:55:14.145 --> 00:55:16.725
Um, and, and test accessibility.

1365
00:55:17.025 --> 00:55:19.965
Um, so, you know, in younger women, um,

1366
00:55:20.015 --> 00:55:22.485
which I think have a lot of good data to support use

1367
00:55:22.485 --> 00:55:25.325
of coronary CTA in, in that particular population.

1368
00:55:25.525 --> 00:55:28.445
I, I try to favor CTA when, when I can get it, um,

1369
00:55:28.445 --> 00:55:29.885
quickly enough for evaluation.

1370
00:55:30.465 --> 00:55:32.805
Um, but I would say it depends a lot on like individual

1371
00:55:32.805 --> 00:55:35.765
patient characteristics, like what I think I can get

1372
00:55:35.765 --> 00:55:37.725
for them and, and what what they can do,

1373
00:55:37.865 --> 00:55:39.405
can they walk on the treadmill, things like that.

1374
00:55:41.275 --> 00:55:42.815
Thanks. And back, back to Tim.

1375
00:55:43.075 --> 00:55:46.055
Um, you know, I I, during your talk about the fish

1376
00:55:46.055 --> 00:55:49.135
and chip study, you mentioned that the incorporation of FFR

1377
00:55:49.595 --> 00:55:51.055
for a couple years was supported

1378
00:55:51.055 --> 00:55:53.655
to develop the amazing data that you showed us.

1379
00:55:53.915 --> 00:55:56.615
What's the status now in, in the uk?

1380
00:55:56.675 --> 00:55:59.295
Is, is it kind of routinely available, um,

1381
00:55:59.395 --> 00:56:00.575
for everybody to use?

1382
00:56:01.605 --> 00:56:05.545
So, uh, well back in 20 17, 20 18, there were no,

1383
00:56:05.685 --> 00:56:06.825
no hospitals using it.

1384
00:56:06.825 --> 00:56:09.585
And I believe now there's over 80, um, in which available

1385
00:56:09.645 --> 00:56:12.425
as a, as a, um, option for a second line test.

1386
00:56:12.725 --> 00:56:14.905
So the growth has been quite phenomenal and,

1387
00:56:14.925 --> 00:56:17.465
and I'm sure that was, um, supported majority

1388
00:56:17.645 --> 00:56:18.865
by the centralized funding.

1389
00:56:19.085 --> 00:56:21.025
Uh, and they actually rolled it out

1390
00:56:21.025 --> 00:56:22.265
for a successive third year

1391
00:56:22.385 --> 00:56:24.245
'cause they thought it was a, such a successful program.

1392
00:56:24.905 --> 00:56:27.565
Um, so it, it, you know, the barriers

1393
00:56:27.835 --> 00:56:30.565
that are when they're lifted, it shows that we'll embrace it

1394
00:56:30.565 --> 00:56:31.925
and do utilize the test.

1395
00:56:32.145 --> 00:56:34.205
Um, not, you know, not every hospital decides that they want

1396
00:56:34.205 --> 00:56:35.245
to continue with that type program.

1397
00:56:35.785 --> 00:56:38.445
Um, and that's, uh, as, as we discussed earlier, often down

1398
00:56:38.445 --> 00:56:40.045
to resources, um,

1399
00:56:40.145 --> 00:56:42.565
and, um, sort of, uh, what the local, uh,

1400
00:56:42.695 --> 00:56:44.925
favoritism is in terms of, uh, expertise.

1401
00:56:45.025 --> 00:56:47.005
But the, uh, but the availability is,

1402
00:56:47.145 --> 00:56:48.925
is not in every hospital, but it's widespread

1403
00:56:48.945 --> 00:56:50.405
and it is available in NHS

1404
00:56:50.405 --> 00:56:52.405
and should anybody want to use it, they can do so

1405
00:56:52.505 --> 00:56:53.645
and get funded for it.

1406
00:56:53.985 --> 00:56:56.445
So that's the key bit. Uh, uh, if, if hospitals want

1407
00:56:56.445 --> 00:56:58.765
to use it, they can do so and get using it.

1408
00:57:00.135 --> 00:57:01.685
Great, thanks. Um, Michelle,

1409
00:57:01.705 --> 00:57:04.485
can I ask you a question about sort of generalizability,

1410
00:57:04.585 --> 00:57:05.645
you know, you work at one

1411
00:57:05.645 --> 00:57:07.125
of the top centers in the United States

1412
00:57:07.265 --> 00:57:09.965
and, you know, have high quality people in every area,

1413
00:57:10.465 --> 00:57:11.925
you know, out, out in the community.

1414
00:57:12.585 --> 00:57:13.925
Um, is the,

1415
00:57:14.865 --> 00:57:19.245
is doing C-C-T-A-A-A big lift in in terms of expertise

1416
00:57:19.945 --> 00:57:21.765
and getting the kind of results and,

1417
00:57:21.785 --> 00:57:24.965
and then incorporating FFR, uh, the kind of results

1418
00:57:24.965 --> 00:57:26.685
that you demonstrated in precise

1419
00:57:26.705 --> 00:57:28.885
or that Tim showed in in fish and chips?

1420
00:57:29.565 --> 00:57:31.705
That's a great question. You know, first I'll say

1421
00:57:31.705 --> 00:57:34.305
that precise did try to be relatively pragmatic in

1422
00:57:34.305 --> 00:57:36.425
that sense in terms of getting kind

1423
00:57:36.425 --> 00:57:39.105
of average patients coming in with chest pain,

1424
00:57:39.285 --> 00:57:40.345
um, for evaluation.

1425
00:57:40.965 --> 00:57:42.465
Um, I think, you know, two things

1426
00:57:42.465 --> 00:57:44.505
that I'll say about accessibility, like

1427
00:57:45.215 --> 00:57:46.865
more locally in the community, um,

1428
00:57:46.885 --> 00:57:48.345
you need specialized equipment

1429
00:57:48.405 --> 00:57:49.785
and you need need good eyes,

1430
00:57:49.855 --> 00:57:51.625
like the right readers that are trained.

1431
00:57:52.205 --> 00:57:53.905
Um, so I think that those two things are,

1432
00:57:54.085 --> 00:57:55.305
are really important and,

1433
00:57:55.365 --> 00:57:58.585
and that, um, that resource, um, sometimes may have

1434
00:57:58.585 --> 00:58:00.705
to be more centralized, um, which,

1435
00:58:00.705 --> 00:58:02.625
which I think isn't the case in many places.

1436
00:58:04.015 --> 00:58:06.675
That's great. Thanks. Um, so,

1437
00:58:07.935 --> 00:58:08.935
Oh, go ahead. The

1438
00:58:08.935 --> 00:58:11.355
problems in the uk you know, we had to massively expand.

1439
00:58:11.495 --> 00:58:13.475
Uh, we threw away all of our treadmills in the first

1440
00:58:13.545 --> 00:58:17.475
iteration of Einsteins had to buy all these ct, but,

1441
00:58:17.575 --> 00:58:19.515
but key to everything is the workforce, I think,

1442
00:58:19.515 --> 00:58:21.075
and Michelle's touched upon, you know, um,

1443
00:58:21.135 --> 00:58:22.395
not just the readers, but the people

1444
00:58:22.395 --> 00:58:25.235
who are performing the tests, uh, you know, buying a CT scan

1445
00:58:25.235 --> 00:58:27.475
and getting under is actually, um, uh,

1446
00:58:27.475 --> 00:58:29.875
easier than getting a trained radiographer who's able

1447
00:58:29.875 --> 00:58:32.035
to do the, uh, the scanning for you, uh,

1448
00:58:32.055 --> 00:58:33.955
and also do a high quality scan high.

1449
00:58:33.955 --> 00:58:35.715
And for me, that's still the major issue in terms

1450
00:58:35.715 --> 00:58:38.195
of expansion, education of the readers, training

1451
00:58:38.215 --> 00:58:40.755
of the readers be the radiologists or cardiologists.

1452
00:58:40.955 --> 00:58:42.155
I think that workforce, you're able

1453
00:58:42.155 --> 00:58:43.875
to do the scans, it's still a major problem.

1454
00:58:45.175 --> 00:58:47.225
Yeah, I think what we're seeing is that the, uh,

1455
00:58:47.585 --> 00:58:51.065
a fairly straightforward part is for us, for instance, to do

1456
00:58:51.655 --> 00:58:55.745
centralized readings of, of advanced imaging like cardiac mr

1457
00:58:55.805 --> 00:58:58.465
or ct, but training, as you said,

1458
00:58:58.485 --> 00:59:01.785
the people out in the community to, to acquire the images

1459
00:59:01.815 --> 00:59:03.985
with quality is, is just a different hurdle,

1460
00:59:04.605 --> 00:59:06.625
but, uh, we, we really have to overcome

1461
00:59:07.365 --> 00:59:08.465
as we come toward the end.

1462
00:59:08.525 --> 00:59:10.385
Let me ask you both about cost

1463
00:59:10.445 --> 00:59:12.305
and just really on opinion based.

1464
00:59:12.425 --> 00:59:15.745
I know Tim, you, you specifically mentioned you'll be, um,

1465
00:59:15.855 --> 00:59:18.145
calculate, you know, doing the analysis of the cost data

1466
00:59:18.145 --> 00:59:19.225
and fish and chips and,

1467
00:59:19.245 --> 00:59:20.385
and Michelle, you know,

1468
00:59:20.385 --> 00:59:22.005
you were involved in the promise trial

1469
00:59:22.005 --> 00:59:23.445
where there's cost and precise.

1470
00:59:23.445 --> 00:59:24.485
We'll have that eventually,

1471
00:59:24.585 --> 00:59:28.975
but, um, just, just on a qualitative basis, so,

1472
00:59:29.475 --> 00:59:32.375
you know, if you think about incorporating CCTA plus minus

1473
00:59:32.535 --> 00:59:35.615
FFR and what happens downstream, do you think this will be

1474
00:59:36.205 --> 00:59:39.455
cost effective, cost increase, cost neutral?

1475
00:59:40.825 --> 00:59:42.685
No, I think that there is some upfront

1476
00:59:42.835 --> 00:59:44.125
cost associated with it.

1477
00:59:44.265 --> 00:59:46.685
Um, not just in terms of the imaging itself,

1478
00:59:46.705 --> 00:59:47.845
but then we've seen

1479
00:59:47.845 --> 00:59:50.165
that there's a little bit more revascularization and,

1480
00:59:50.225 --> 00:59:51.325
and cath thereafter,

1481
00:59:51.685 --> 00:59:54.365
although, um, cath that seems to be indicated thereafter.

1482
00:59:54.945 --> 00:59:56.605
Um, so I think there's some upfront cost,

1483
00:59:56.625 --> 00:59:59.845
but I think if you zoom out to like years down the road,

1484
00:59:59.845 --> 01:00:02.005
particularly if CT really helps us

1485
01:00:02.525 --> 01:00:04.805
optimize our preventive therapy, like I,

1486
01:00:04.885 --> 01:00:07.245
I think if you're able to see it on that scale, I,

1487
01:00:07.405 --> 01:00:10.005
I would expect that the cost would be cost saving like over

1488
01:00:10.005 --> 01:00:12.245
the long term, but I think there might be a little bit more

1489
01:00:12.245 --> 01:00:15.245
upfront, um, with the revascularization and things

1490
01:00:16.395 --> 01:00:18.975
That's Michelle's hit the nail on the head.

1491
01:00:19.395 --> 01:00:22.175
Um, in, in reality, you know, CT is gonna be, uh,

1492
01:00:22.175 --> 01:00:23.655
effective 'cause it'll save lives.

1493
01:00:23.655 --> 01:00:25.095
You get more patients on medications,

1494
01:00:25.155 --> 01:00:26.855
you get fewer heart attacks, um,

1495
01:00:26.915 --> 01:00:28.935
and hospital admissions in the long term.

1496
01:00:29.055 --> 01:00:30.695
I think that would be great. You add in the

1497
01:00:30.695 --> 01:00:32.095
CTFR reduces up downstream?

1498
01:00:32.155 --> 01:00:34.695
Yes, and that'll be where you, you gain the cost saving,

1499
01:00:34.995 --> 01:00:37.655
but you do that initial increase in, um, PCIs,

1500
01:00:37.705 --> 01:00:39.935
which I think will obviously increase the cost,

1501
01:00:39.935 --> 01:00:41.855
but it'll be by reduction

1502
01:00:41.915 --> 01:00:44.975
of unnecessary invasive corona angiograms in a large portion

1503
01:00:45.225 --> 01:00:48.295
population, which is a, a cost saving, um, uh, strategy.

1504
01:00:48.555 --> 01:00:50.895
So overall, I think probably, um, uh, you know,

1505
01:00:51.115 --> 01:00:53.575
at worst cost neutral mightly save money in terms

1506
01:00:53.575 --> 01:00:55.015
of both things in the longer term

1507
01:00:55.395 --> 01:00:57.775
and there is data out there, be it forecast, you know,

1508
01:00:57.775 --> 01:00:58.975
the US and um,

1509
01:00:59.195 --> 01:01:01.695
and UK versions of, uh, cost effectiveness strategies.

1510
01:01:01.995 --> 01:01:04.295
And then I will do it hopefully with fish chip too.

1511
01:01:04.825 --> 01:01:06.415
Along the lines of education.

1512
01:01:06.555 --> 01:01:08.615
Uh, Michelle, you know, is there anything

1513
01:01:08.615 --> 01:01:12.095
that people listening to us today as, as they go back

1514
01:01:12.095 --> 01:01:16.615
to their, uh, practices, um, incorporating FFR,

1515
01:01:16.875 --> 01:01:18.495
you know, as, as you see

1516
01:01:18.495 --> 01:01:21.775
that expanding at your center at Duke is,

1517
01:01:21.835 --> 01:01:24.175
is there any specifics around education

1518
01:01:24.315 --> 01:01:25.935
for the referring physicians

1519
01:01:26.355 --> 01:01:29.775
or is it very simply just incorporated into reports?

1520
01:01:30.755 --> 01:01:31.755
How do you do that?

1521
01:01:32.885 --> 01:01:34.525
I mean, I think every case is an

1522
01:01:34.525 --> 01:01:35.805
opportunity for education.

1523
01:01:36.025 --> 01:01:38.525
Um, I think that like when you get these, um,

1524
01:01:38.535 --> 01:01:41.485
these cases back and you have a lot of FFR data that you get

1525
01:01:41.485 --> 01:01:44.205
to integrate, I think that every time you write a note about

1526
01:01:44.205 --> 01:01:47.045
it or every time you, you go through like the patient case

1527
01:01:47.045 --> 01:01:49.445
and how that, how that impacted your management, I think

1528
01:01:49.445 --> 01:01:51.805
that that's an opportunity for education from the,

1529
01:01:52.035 --> 01:01:53.245
from the referral center.

1530
01:01:53.445 --> 01:01:55.445
I think that that's, um, that's one opportunity.

1531
01:01:55.885 --> 01:01:58.285
I think that like also it's good for, for people

1532
01:01:58.285 --> 01:02:00.645
to understand that this resource is available as

1533
01:02:00.785 --> 01:02:02.245
as it becomes, as we get more

1534
01:02:02.245 --> 01:02:03.765
and more data to show its importance.

1535
01:02:04.305 --> 01:02:06.805
Um, so educational sessions like this I think are good.

1536
01:02:07.115 --> 01:02:08.115
Yeah.

1537
01:02:08.955 --> 01:02:11.245
Well, that's great. Uh, thank you both so much

1538
01:02:11.425 --> 01:02:12.885
and thanks to everyone for all the

1539
01:02:13.045 --> 01:02:14.125
questions that we're pouring in.

1540
01:02:14.165 --> 01:02:16.005
I, I think we could have gone, we can go on

1541
01:02:16.005 --> 01:02:17.925
for another hour, but I'm afraid we have to stop.

1542
01:02:18.025 --> 01:02:21.445
So I just wanna thank, uh, you for your, the great questions

1543
01:02:21.465 --> 01:02:23.245
and thanks Michelle and Tim for the,

1544
01:02:23.505 --> 01:02:26.365
the comprehensive answers and the engagements.

1545
01:02:26.505 --> 01:02:29.725
Um, thanks very much to the folks at Cardiovascular Business

1546
01:02:29.725 --> 01:02:31.805
and also the folks at Heart Flow, uh,

1547
01:02:31.805 --> 01:02:32.885
for bringing the panel together

1548
01:02:32.885 --> 01:02:33.885
and allowing us to do this

1549
01:02:33.945 --> 01:02:35.765
to help celebrate World Heart Day.

1550
01:02:36.265 --> 01:02:39.125
Uh, the team at Cardiovascular Business will be emailing you

1551
01:02:39.245 --> 01:02:42.285
a link to the webinar so you can listen again

1552
01:02:42.385 --> 01:02:45.205
to our wonderful words and share them with your colleagues.

1553
01:02:45.585 --> 01:02:47.045
Uh, have a great rest of the day

1554
01:02:47.305 --> 01:02:49.325
and, um, enjoy World Heart Day.

1555
01:02:49.325 --> 01:02:50.765
Thanks so much. Bye.