A Prospective, Multicenter, Randomized Controlled Trial to Investigate the Value of Coronary CT Angiography in the Understanding and Management of Coronary Calcium (The Optimal Trial)

A Prospective, Multicenter, Randomized Controlled Trial to Investigate the Value of Coronary CT Angiography in the Understanding and Management of Coronary Calcium

The OPTIMAL randomized clinical trial has been designed to compare two imaging strategies and to test the hypothesis that a calcium modification strategy informed by coronary CT angiography (CCTA) will improve procedural efficiency and effectiveness compared with the current standard of care (IVUS-guided PCI) while achieving similar clinical outcomes in patients with hemodynamically significant calcified coronary artery disease.

Study Overview

• Status: Recruiting
• Conditions: Myocardial Ischemia; Heart Diseases; Cardiovascular Diseases; Vascular Diseases; Coronary Artery Disease; Arteriosclerosis; Arterial Occlusive Diseases
• Intervention / Treatment: Device: CT(Computed Tomography) guided Percutaneous Coronary Intervention; Device: IVUS (Intravascular Ultrasound) guided Percutaneous Coronary Intervention

Detailed Description

The OPTIMAL Trial is a prospective, multicenter, randomized controlled study evaluating whether a coronary CT angiography (CCTA)-guided calcium modification strategy can improve the treatment of patients with hemodynamically significant, calcified coronary artery disease undergoing percutaneous coronary intervention (PCI).

Seven hundred patients with flow-limiting stenosis (FFRCT ≤0.80) and moderate-to-severe calcification on CCTA will be randomized 1:1 to either CCTA-guided or intravascular ultrasound (IVUS)-guided calcium modification. The study includes two co-primary endpoints: (1) superiority in final minimal stent area assessed by IVUS, and (2) non-inferiority in 12-month target vessel failure (cardiac death, target-vessel myocardial infarction, or ischemia-driven revascularization).

CCTA-guided strategy uses advanced calcium characterization to inform pre-procedural planning and selection of plaque modification techniques. IVUS-guided strategy follows contemporary intravascular imaging-based criteria for plaque preparation and PCI optimization.

The trial aims to determine whether leveraging non-invasive CT-based calcium assessment can enhance procedural efficiency and stent results while maintaining clinical safety comparable to IVUS-guided PCI.

• Study Type: Interventional
• Enrollment (Estimated): 700
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: CAROLINA FOCELLA; Phone Number: 001 917 753 6695; Email: cfocella@crf.org
• Study Contact Backup: Name: CARLOS COLLET, MD,PhD; Phone Number: 001 917 753 6695; Email: carloscollet@gmail.com

Study Locations

• Spain
  • Barcelona, Spain, 08035
    • Recruiting
    • Hospital Universitari Vall Hebron
  • León, Spain
    • Recruiting
    • Hospital Universitario de Leon
  • Madrid, Spain, 28046
    • Recruiting
    • Hospital Universitario La Paz
• United Kingdom
  • Leicester, United Kingdom
    • Not yet recruiting
    • University Hospitals of Leicester NHS Trust
  • London, United Kingdom
    • Not yet recruiting
    • St Bartholomew's Hospital (Barts Health NHS Trust)
  • London, United Kingdom
    • Not yet recruiting
    • St George's University Hospitals NHS Foundations Trust
  • Newcastle, United Kingdom
    • Not yet recruiting
    • Newcastle Hospitals NHS Foundations Trust
  • Oxford, United Kingdom
    • Not yet recruiting
    • John Radcliffe Hospital, Oxford
• United States
  • Massachusetts
    • Boston, Massachusetts, United States, 02115
      • Not yet recruiting
      • Bringham and Women's Hospital
  • Minnesota
    • Minneapolis, Minnesota, United States, 55407
      • Not yet recruiting
      • Minneapolis Heart Institute
  • New Jersey
    • Jersey City, New Jersey, United States, 08837
      • Not yet recruiting
      • HACKENSACK MERIDIAN HEALTH, Inc
  • New York
    • New York, New York, United States, 10032
      • Not yet recruiting
      • Columbia University Irving Medical Center/NewYork-Presbyterian Hospital
    • New York, New York, United States, 14853
      • Not yet recruiting
      • Weill Medical College of Cornell University

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• The subject must be at least 18 years of age and younger than 85 years old
• Subject must have evidence of myocardial ischemia (e.g., stable angina, silent ischemia (ischemia in the absence of chest pain or other anginal equivalents), unstable angina, or acute myocardial infarction) suitable for PCI. Patients with a clinical indication for revascularization presenting with stable coronary artery disease or stabilized acute coronary syndrome defined as follows unstable angina (Braunwald class IB, IC, IIB, IIC, IIIB, IIIC), patients with NSTEMI without high-risk features such as recurrence of chest pain, ST-segment depression>1mm in ≥6 leads plus STsegment elevation in aVR, life-threatening arrhythmias, mechanical complications of MI, resuscitated cardiac arrest, GRACE risk score>140.
• All target vessels must have reference vessel diameter (visually assessed by CCTA) ≥ 2.5 mm
• Subject must provide written informed consent before any study-related procedure

Exclusion Criteria:

• STEMI as the clinical presentation.
• Uncontrolled or recurrent ventricular tachycardia.
• Hemodynamic instability.
• Hemodialysis or peritoneal dialysis.
• Left main coronary artery stenosis > 50%
• Atrial fibrillation, flutter, or arrhythmias during CT acquisition.
• Previous PCI in the target vessel or CABG.
• BMI ≥ 40 kg/m2
• Insufficient CT quality assessed by the Core lab.
• Comorbidity with life expectancy ≤ 2 years.
• Planned major cardiac or non-cardiac surgery within 24 months after the index procedure Note: Major surgery is any invasive operative procedure in which an extensive resection is performed, e.g., a body cavity is entered, organs are removed, or normal anatomy is altered. Note: Minor surgery is an operation on the superficial structures of the body or a manipulative procedure that does not involve a serious risk. Planned minor surgery is not excluded.
• The subject has received a solid organ transplant that is functioning or is active on a waiting list for any solid organ transplants with expected transplantation within 24 months.
• The subject receives immunosuppressant therapy or has known immunosuppressive or severe autoimmune disease that requires chronic immunosuppressive therapy (e.g., human immunodeficiency virus, systemic lupus erythematosus, etc.). Note: corticosteroids are not included as immunosuppressant therapy.
• The subject has previously received or is scheduled to receive radiotherapy to a coronary artery (vascular brachytherapy) or the chest/mediastinum.
• Subject has a platelet count <100,000 cells/mm3 or >700,000 cells/mm3.
• The subject has a documented or suspected hepatic disorder as defined as cirrhosis or Child-Pugh ≥ Class B.
• The subject has a history of bleeding diathesis or coagulopathy or has had a significant gastro-intestinal or significant urinary bleed within the past six months. The subject has had a cerebrovascular accident or transient ischemic neurological attack (TIA) within the past six months, or any prior intracranial bleed, or any permanent neurologic defect, or any known intracranial pathology (e.g., aneurysm, arteriovenous malformation, etc. The subject has a life expectancy <2 years for any non-cardiac cause.
• Subject is currently participating in another investigational drug or device clinical study.
• Pregnant or nursing subjects and those who plan pregnancy in the period up to 2 years following index procedure. Female subjects of child-bearing potential must have a negative pregnancy test done within 7 days prior to the index procedure per site standard test.
• Presence of other anatomic or comorbid conditions, or other medical, social, or psychological conditions that, in the investigator's opinion, could limit the subject's ability to participate in the clinical investigation or to comply with follow-up requirements, or impact the scientific soundness of the clinical investigation results.
• Unable to provide written informed consent (IC).

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: CT-guide calcium modification strategy; Pre-procedural CT will be used to determine lesion characteristics.	Device: CT(Computed Tomography) guided Percutaneous Coronary Intervention; CT will be used to determine lesion characteristics and post-procedural IVUS to confirm correct implantation of stent
Active Comparator: IVUS-guide calcium modification strategy; Pre-procedural IVUS will be used to determine lesion characteristics.	Device: IVUS (Intravascular Ultrasound) guided Percutaneous Coronary Intervention; IVUS will be used to determine lesion characteristics and post-procedural IVUS to confirm correct implantation of stent

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Demonstrate that CT-guided calcium modification results in a superior final MSA Minimal Stent Area (MSA) - Imaging Endpoint (Superiority)	Final post-PCI minimal stent area per target lesion, measured by independent core laboratory using intravascular ultrasound (IVUS). Assesses whether CT-guided calcium modification results in superior stent expansion compared with IVUS-guided PCI.	Perioperative/Periprocedural
Target Vessel Failure (TVF) - Clinical Endpoint (Non-Inferiority)	Composite of cardiac death, target-vessel myocardial infarction (TV-MI), or ischemia-driven target vessel revascularization (ID-TVR). TV-MI and ID-TVR are defined according to ARC-2 and the Fourth Universal Definition of MI.	12 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Procedural efficiency: Procedure time	Time from first angiogram to final angiogram	During PCI
Procedural efficiency:Radiation dose-area product	Dose-area product (DAP) recorded during PCI.	During PCI
Procedural efficiency: Contrast volume	Total contrast volume (mL) used during PCI.IVUS-Derived Mechanistic Endpoints (Core Lab)	During PCI
Procedural Efficiency: Stent Area on Immediate Post-Stent IVUS	MSA prior to any final IVUS-guided optimization.	Perioperative/Periprocedural
Procedural Efficiency: Final Stent Area at Original Minimal Lumen Area (MLA)	Stent area at the co-registered site of the baseline MLA.	Perioperative/Periprocedural
Procedural Efficiency: Final Stent Area at Site of Maximum Calcium Arc	Stent area measured at the co-registered IVUS site with maximal calcium arc	Perioperative/Periprocedural
Procedural Efficiency: Final Stent Area at Site of Maximum Calcium Density	Stent area measured at the co-registered CT-identified region of greatest Hounsfield Unit (HU) calcium density.	Perioperative/Periprocedural
Procedural Efficiency: Relative Stent Expansion	Percentage expansion calculated as: MSA ÷ mean distal reference lumen area × 100.	Perioperative/Periprocedural
Procedural Efficiency: Number of Calcium Fractures	Fractures identified on intermediary IVUS after calcium modification.	Post-modification, pre-stent
Procedural Efficiency: Change in Plaque Attenuation	Change in IVUS plaque characteristics following calcium modification.Angiographic Endpoints	Post-modification, pre-stent
Procedural Efficiency: Final Minimal Lumen Diameter	Minimum lumen diameter by quantitative coronary angiography (QCA)	Perioperative/Periprocedural
Procedural Efficiency: Final Percent Diameter Stenosis	Percent stenosis of treated lesion after PCI, by QCA	Perioperative/Periprocedural
Procedural Efficiency: Final TIMI Flow Grade	Target vessel flow graded 0-3 based on TIMI criteria. Thrombolysis In Myocardial Infarction (TIMI) Flow Grade is a 0-3 angiographic scale used during coronary angiography to describe how well blood is flowing through a coronary artery.TIMI 0 No perfusion, TIMI 1 Penetration without perfusion, TIMI 2 Partial perfusion TIMI 3 Complete perfusion (normal flow)	Perioperative/Periprocedural
Procedural Efficiency: Angiographic Complications	According to Coronary dissection (NHLBI classification)	Day of procedure
Procedural Efficiency: Angiographic Complications	According to Coronary perforation (Ellis classification)	Day of procedure
Procedural Efficiency: Angiographic Complications	Slow-flow / no-reflow	Day of procedure
Procedural Efficiency: Angiographic Complications	Side branch closure (TIMI 0-1)	Day of procedure
Clinical & Safety Outcomes: Procedural Success	Final stenosis <30%, TIMI 3 flow, no angiographic complications, and no in-hospital major adverse cardiac events (MACE).	Perioperative/Periprocedural
Clinical & Safety Outcomes: Periprocedural Myocardial Infarction (Type 4a MI)	Defined by ARC-2 and 4th Universal Definition of MI (troponin criteria + evidence of ischemia).	Day 0-1
Clinical & Safety Outcomes: Stent Thrombosis	Definite or probable stent thrombosis according to ARC-2 definitions.	Up to 12 months
Patient-Reported Outcomes: Residual Angina (SAQ-7 Angina Frequency)	Residual angina defined as SAQ-7 Angina Frequency score <100. Angina frequency represent how often a patient has had angina (chest pain/discomfort) over a recent recall period. Reported as a 0 to 100 scale: 100 = no angina; 0 = angina occurring very frequently	12 months
Patient-Reported Outcomes: Change in Angina (SAQ-7)	Change in angina frequency domain score; positive values indicate improvement. Angina frequency represent how often a patient has had angina (chest pain/discomfort) over a recent recall period. Reported as a 0 to 100 scale: 100 = no angina; 0 = angina occurring very frequently	Baseline to 12 months

Collaborators and Investigators

• Sponsor: Fundación EPIC

Publications and helpful links

General Publications

• Collet C, Sonck J, Vandeloo B, Mizukami T, Roosens B, Lochy S, Argacha JF, Schoors D, Colaiori I, Di Gioia G, Kodeboina M, Suzuki H, Van 't Veer M, Bartunek J, Barbato E, Cosyns B, De Bruyne B. Measurement of Hyperemic Pullback Pressure Gradients to Characterize Patterns of Coronary Atherosclerosis. J Am Coll Cardiol. 2019 Oct 8;74(14):1772-1784. doi: 10.1016/j.jacc.2019.07.072.
• Sonck J, Nagumo S, Norgaard BL, Otake H, Ko B, Zhang J, Mizukami T, Maeng M, Andreini D, Takahashi Y, Jensen JM, Ihdayhid A, Heggermont W, Barbato E, Mileva N, Munhoz D, Bartunek J, Updegrove A, Collinsworth A, Penicka M, Van Hoe L, Leipsic J, Koo BK, De Bruyne B, Collet C. Clinical Validation of a Virtual Planner for Coronary Interventions Based on Coronary CT Angiography. JACC Cardiovasc Imaging. 2022 Jul;15(7):1242-1255. doi: 10.1016/j.jcmg.2022.02.003. Epub 2022 Apr 13.
• Tajima A, Bouisset F, Ohashi H, Sakai K, Mizukami T, Rizzini ML, Gallo D, Chiastra C, Morbiducci U, Ali ZA, Spratt JC, Ando H, Amano T, Kitslaar P, Wilgenhof A, Sonck J, De Bruyne B, Collet C. Advanced CT Imaging for the Assessment of Calcific Coronary Artery Disease and PCI Planning. J Soc Cardiovasc Angiogr Interv. 2024 Mar 26;3(3Part B):101299. doi: 10.1016/j.jscai.2024.101299. eCollection 2024 Mar.
• Monizzi G, Sonck J, Nagumo S, Buytaert D, Van Hoe L, Grancini L, Bartorelli AL, Vanhoenacker P, Simons P, Bladt O, Wyffels E, De Bruyne B, Andreini D, Collet C. Quantification of calcium burden by coronary CT angiography compared to optical coherence tomography. Int J Cardiovasc Imaging. 2020 Dec;36(12):2393-2402. doi: 10.1007/s10554-020-01839-z. Epub 2020 Nov 17.
• Collet C, Collison D, Mizukami T, McCartney P, Sonck J, Ford T, Munhoz D, Berry C, De Bruyne B, Oldroyd K. Differential Improvement in Angina and Health-Related Quality of Life After PCI in Focal and Diffuse Coronary Artery Disease. JACC Cardiovasc Interv. 2022 Dec 26;15(24):2506-2518. doi: 10.1016/j.jcin.2022.09.048. Epub 2022 Nov 30.

Study record dates

Study Major Dates

• Study Start (Actual): December 22, 2025
• Primary Completion (Estimated): December 15, 2029
• Study Completion (Estimated): January 1, 2030

Study Registration Dates

• First Submitted: November 28, 2025
• First Submitted That Met QC Criteria: December 12, 2025
• First Posted (Actual): December 16, 2025

Study Record Updates

• Last Update Posted (Actual): February 10, 2026
• Last Update Submitted That Met QC Criteria: February 9, 2026
• Last Verified: February 1, 2026

More Information

Terms related to this study

• Keywords: CT; IVUS
• Additional Relevant MeSH Terms: Coronary Disease; Cardiovascular Diseases; Heart Diseases; Vascular Diseases; Coronary Artery Disease; Myocardial Ischemia; Arteriosclerosis; Arterial Occlusive Diseases
• Other Study ID Numbers: EPIC46-THE OPTIMAL TRIAL

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No