Optical Coherence Tomography Morphologic and Fractional Flow Reserve Assessment in Diabetes Mellitus Patients (COMBINE)

Combined Optical Coherence Tomography Morphologic and Fractional Flow Reserve Hemodynamic Assessment of Non-Culprit Lesions to Better Predict Adverse Event Outcomes in Diabetes Mellitus Patients. COMBINE (OCT-FFR) Prospective Register

Title:

Combined Optical Coherence Tomography Morphologic and Fractional Flow Reserve Hemodynamic Assessment of Non-Culprit Lesions to Better Predict Adverse Event Outcomes in Diabetes Mellitus Patients COMBINE (OCT-FFR) Prospective Register

To study the natural evolution of patients with at least one intermediate angiographic but non-hemodynamic significant stenotic lesion, in two subgroups of patients, with TCFA vs. no TCFA as detected by OCT imaging and to compare these two groups of patients with each other as well as to a subset of patients with FFR-positive and PCI-treated intermediate lesions on future MACE.

Study Overview

• Status: Completed
• Conditions: Coronary Artery Disease; Diabetes Mellitus; Coronary Atheroscleroses
• Intervention / Treatment: Procedure: Optical Coherence Tomography

Detailed Description

Hypothesis Diabetes Mellitus (DM) patients with angiographically intermediate coronary lesions remain at risk for future MACE events, including those patients with fractional flow reserve (FFR) negative lesions. Use of FFR measurements combined with Optimal Coherence Tomography (OCT) detection of thin-cap fibroatheroma (TCFA) in will help predict future MACE rates.

Objective To study the natural evolution of patients with at least one intermediate angiographic but non-hemodynamic significant stenotic lesion, in two subgroups of patients, with TCFA vs. no TCFA as detected by OCT imaging and to compare these two groups of patients with each other as well as to a subset of patients with FFR-positive and PCI-treated intermediate lesions on future MACE.

Design Prospective, open label natural history registry. DM patients bearing target lesions {Any de novo lesion with an angiographic visual estimation of ≥ 40%- ≤ 80% Diameter Stenosis (DS) that is located in a non-grafted coronary segment. In patients with an MI at presentation the target lesion should be different from the culprit lesion} and have undergone FFR and OCT imaging as for clinical routine will be prospectively enrolled and followed. Patients with negative FFR (> 0.80) will be divided in two categories depending on corelab OCT imaging findings: No-TCFA (cap thickness >65µ) (Group A) or TCFA (cap thickness ≤ 65µ) (group B). All patients that had a positive FFR and therefore have been treated with PCI as per standard care in all target lesions will also be followed (group C), however if after the PCI there is at least one remaining target lesion where FFR was negative these patients should be followed in group A or B depending on the OCT findings. Clinical endpoints at 1.5 year will be recorded.

The investigators strongly recommend that all major epicardial coronary vessels of stentable size that show any form of atherosclerosis to be interrogated with FFR and OCT.

The investigators strongly recommend to not perform cap thickness measurements in the cathlab. The plaque cap thickness as measured in the corelab will not be disclosed to operators and patients.

Population Patients aged ≥18 years Diabetes mellitus (DM) patients with any presentation. Coronary angiography, FFR and OCT imaging in at least one coronary de novo stenosis in a native vessel with a visually estimated diameter of stenosis (DS) of ≥ 40%-≤ 80% (target lesion).

Angiographic criteria target lesion:

(i) ≥ 40%-≤ 80% diameter stenosis (DS) (ii) de novo lesion located in native non-grafted vessel (iii) target lesion reference diameter of ≥ 2.0 mm (iv) TIMI 3 flow

Primary Endpoint The per patient incidence of the target lesion(s) related composite MACE defined as Cardiac Death, MI, clinically-driven target lesion revascularisation or hospitalization due to unstable or progressive angina at 18 months in the FFR-negative No-TCFA (Group A) and FFR-negative TCFA (Group B).

Statistics This is an observational study (prospective natural history register) where no randomization takes place, therefore a power calculation is strictly not necessary.

However, in order to observe meaningful differences between groups (as described in the design) and deduct founded conclusions, the minimal number of patients required was calculated as follows. The target lesion related primary endpoint at 18 months in the A and B group respectively are assumed to be 5 % and 20% respectively. Taking into account an expected loss in FU of 7%, a total of 500 patients enrolled in the study will provide 80% power to reject the null hypothesis with 5% type I error (alpha). The enrolment in group C will stop after the first 166 patients have been enrolled in this group. The rest of the rest of 334 patients will be distributed in groups A and B depending on the OCT corelab findings. Nul hypothesis: the MACE rate in group B is not different from group A.

• Study Type: Observational
• Enrollment (Actual): 550

Contacts and Locations

Study Locations

• Netherlands
  • Overijssel
    • Zwolle, Overijssel, Netherlands, 8025 AB
      • Isala

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

• Sampling Method: Probability Sample

Study Population

The COMBINE (OCT-FFR) Trial is an investigator driven study: a prospective natural history registry. Patients aged ≥ 18 years bearing target lesions (see definition section) that fulfil the inclusion criteria and have undergone FFR and OCT imaging as per clinical practice will be enrolled in the study.

Description

Inclusion Criteria:

1. Age ≥ 18 years
2. History of DM with any indication for angiography (Stable Angina (SA) or any type of Acute Coronary Syndrome (ACS) including ST-Elevation MI).
3. Coronary angiography, including FFR and OCT imaging of at least one coronary de novo stenosis in a native not-grafted vessel with a visually estimated diameter stenosis (DS) of ≥ 40 - ≤ 80% (target lesion) . Target lesion should be other than the culprit lesion(s) in patients presenting with MI (STEMI or non-STEMI).

Exclusion Criteria:

1. TIMI flow < 3 in the target lesion(s)
2. Target lesion reference diameter (on visual estimation) < 2.0 mm
3. Known left ventricular ejection fraction <30%
4. Known malignancy
5. Life expectancy < 2 years
6. Unwilling or unable to provide inform consent

Study Plan

How is the study designed?

Number of groups / cohorts

3

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
Group A; Patients with negative FFR (> 0.80) in the target lesion & decided on OCT (Optical Coherence Tomography) imaging findings with NO thin-cap fibroatheroma	Procedure: Optical Coherence Tomography; Patients aged ≥ 18 years bearing target lesions that fulfil the inclusion criteria and have undergone FFR and OCT imaging as per clinical practice will be enrolled in the study.; Other Names: OCT
Group B; Patients with negative FFR (> 0.80) in the target lesion & decided on OCT (Optical Coherence Tomography) imaging findings presence of ≥ thin-cap fibroatheroma	Procedure: Optical Coherence Tomography; Patients aged ≥ 18 years bearing target lesions that fulfil the inclusion criteria and have undergone FFR and OCT imaging as per clinical practice will be enrolled in the study.; Other Names: OCT
Group C; Patients hosting FFR-positive target lesions that have been treated with PCI as per standard care and have further no TCFA lesions.	Procedure: Optical Coherence Tomography; Patients aged ≥ 18 years bearing target lesions that fulfil the inclusion criteria and have undergone FFR and OCT imaging as per clinical practice will be enrolled in the study.; Other Names: OCT

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
The per patient incidence of the target lesion(s) related composite MACE	The per patient incidence of the target lesion(s) related composite MACE defined as Cardiac Death, MI, clinically-driven target lesion revascularisation or hospitalization due to unstable or progressive angina at 18 months in the FFR-negative No-TCFA (Group A) and FFR-negative TCFA (Group B).	18 months after procedure

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
The per patient incidence of the target lesion(s) related composite MACE:	Cardicac death, MI, clinically- driven revascularization or hospitalization due to unstable or progressive angina between FFR-negative TCFA (Group B) and the group of patients with PCI-treated FFR-positive lesions (Group C).	18 months after procedure
The per patient incidence composite MACE	The per patient incidence composite MACE: Cardiac death, MI, any clinically driven-revascularization or hospitalization due to unstable or progressive angina between FFR-negative TCFA (Group B) and the group of patients with PCI treated FFR positive lesions (Group C).	18 months after procedure
The incidence of MACE (Cardiac death, MI, any clinically driven-revascularization or hospitalization due to unstable or progressive angina)	deriving from non PCI treated lesions between TCFA hosting patients anywhere in the major coronary of stentable size vs. patients with no TCFA (this analysis will be run in the total pool of patients after treatment of all FFR positive lesions and does not take in account the angiographic severity of the lesions ie. the location of the TCFA can be elsewhere than the target lesion )	18 months after procedure

Collaborators and Investigators

• Sponsor: Diagram B.V.
• Collaborators: Isala; St. Jude Medical Nederland B.V.
• Investigators: Principal Investigator: E Kedhi, MD PhD, Erasmus Academical Hospital Brussels

Publications and helpful links

General Publications

• Kennedy MW, Fabris E, Ijsselmuiden AJ, Nef H, Reith S, Escaned J, Alfonso F, van Royen N, Wojakowski W, Witkowski A, Indolfi C, Ottervanger JP, Suryapranata H, Kedhi E. Combined optical coherence tomography morphologic and fractional flow reserve hemodynamic assessment of non- culprit lesions to better predict adverse event outcomes in diabetes mellitus patients: COMBINE (OCT-FFR) prospective study. Rationale and design. Cardiovasc Diabetol. 2016 Oct 10;15(1):144. doi: 10.1186/s12933-016-0464-8.
• Kedhi E, Berta B, Roleder T, Hermanides RS, Fabris E, IJsselmuiden AJJ, Kauer F, Alfonso F, von Birgelen C, Escaned J, Camaro C, Kennedy MW, Pereira B, Magro M, Nef H, Reith S, Al Nooryani A, Rivero F, Malinowski K, De Luca G, Garcia Garcia H, Granada JF, Wojakowski W. Thin-cap fibroatheroma predicts clinical events in diabetic patients with normal fractional flow reserve: the COMBINE OCT-FFR trial. Eur Heart J. 2021 Dec 1;42(45):4671-4679. doi: 10.1093/eurheartj/ehab433.
• Fabris E, Berta B, Hommels T, Roleder T, Hermanides RS, Rivero F, von Birgelen C, Escaned J, Camaro C, Kennedy MW, Pereira B, Magro M, Nef H, Reith S, Roleder-Dylewska M, Gasior P, Malinowski KP, De Luca G, Garcia-Garcia HM, Granada JF, Wojakowski W, Kedhi E. Long-term outcomes of patients with normal fractional flow reserve and thin-cap fibroatheroma. EuroIntervention. 2023 Feb 6;18(13):e1099-e1107. doi: 10.4244/EIJ-D-22-00306.
• Fabris E, Berta B, Roleder T, Hermanides RS, IJsselmuiden AJJ, Kauer F, Alfonso F, von Birgelen C, Escaned J, Camaro C, Kennedy MW, Pereira B, Magro M, Nef H, Reith S, Roleder-Dylewska M, Gasior P, Malinowski K, De Luca G, Garcia-Garcia HM, Granada JF, Wojakowski W, Kedhi E. Thin-Cap Fibroatheroma Rather Than Any Lipid Plaques Increases the Risk of Cardiovascular Events in Diabetic Patients: Insights From the COMBINE OCT-FFR Trial. Circ Cardiovasc Interv. 2022 May;15(5):e011728. doi: 10.1161/CIRCINTERVENTIONS.121.011728. Epub 2022 Apr 29.

Helpful Links

• Cardiovascular Diabetology

Study record dates

Study Major Dates

• Study Start (Actual): March 26, 2015
• Primary Completion (Actual): June 30, 2020
• Study Completion (Actual): February 28, 2021

Study Registration Dates

• First Submitted: December 8, 2016
• First Submitted That Met QC Criteria: December 8, 2016
• First Posted (Estimate): December 12, 2016

Study Record Updates

• Last Update Posted (Actual): September 5, 2021
• Last Update Submitted That Met QC Criteria: August 30, 2021
• Last Verified: August 1, 2021

More Information

Terms related to this study

• Keywords: Diabetes Mellitus; Optical Coherence Tomography; Fractional Flow Reserve; Thincap fibroatheroma
• Additional Relevant MeSH Terms: Heart Diseases; Cardiovascular Diseases; Vascular Diseases; Glucose Metabolism Disorders; Metabolic Diseases; Arteriosclerosis; Arterial Occlusive Diseases; Endocrine System Diseases; Coronary Disease; Coronary Artery Disease; Myocardial Ischemia; Diabetes Mellitus; Atherosclerosis
• Other Study ID Numbers: 9241

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO