The Value of Fractional Flow Reserve Derived from Coronary ...€¦ · Fractional Flow Reserve (FFR) derived from Coronary Computed Tomographic Angiography (CCTA) (CT-FFR) compared
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Funding Sponsor: Primary Funding Institution: Northwell Health Foundation:
Lenox Hill. Funded by: Charitable Contribution for CT-
FFR study to be supervised by Dr. Michael Poon.
Address: Northwell Health
Phone Number: 646-766-7131
Study Product: Device Name – Coronary Tomographic Fractional Flow
Reserve; HeartFlow CT-FFR
Protocol Number: n/a
IND/IDE Number: n/a
Performance Site(s): Lenox Hill Hospital, New York, NY
Date: 12/22/16
Amended: 8/26/2017 3.21.2019
CONFIDENTIAL
This document is confidential and the property of the North Shore-LIJ Health System. No
part of it may be transmitted, reproduced, published, or used by other persons without
prior written authorization from the study sponsor.
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Table of Contents
STUDY SUMMARY ................................................................................................................................................... 1
1 PREVIOUS STUDY HISTORY ....................................................................................................................... 2
2 BRIEF SUMMARY OF RESEARCH .............................................................................................................. 2
3.1 BACKGROUND .................................................................................................................................................. 3 3.2 INVESTIGATIONAL AGENT................................................................................................................................ 3 3.3 PRECLINICAL DATA ......................................................................................................................................... 4 3.4 CLINICAL DATA TO DATE ................................................................................................................................ 4 3.5 DOSE RATIONALE AND RISK/BENEFITS ............................................................................................................ 4
4 STUDY OBJECTIVES ...................................................................................................................................... 4
5 RESOURCES AVAILABLE TO CONDUCT THE HUMAN RESEARCH ................................................ 5
6 STUDY DESIGN ................................................................................................................................................ 5
6.1 GENERAL DESIGN ............................................................................................................................................ 5 6.2 PRIMARY STUDY ENDPOINTS ........................................................................................................................... 6 6.3 SECONDARY STUDY ENDPOINTS ...................................................................................................................... 7 6.4 PRIMARY SAFETY ENDPOINTS .......................................................................................................................... 7
7 SUBJECT SELECTION AND WITHDRAWAL............................................................................................ 7
7.1 INCLUSION CRITERIA ....................................................................................................................................... 7 7.2 EXCLUSION CRITERIA ...................................................................................................................................... 8 7.3 VULNERABLE POPULATIONS ............................................................................................................................ 8 7.4 SUBJECT RECRUITMENT AND SCREENING ........................................................................................................ 9 7.5 CONSENT PROCESS .......................................................................................................................................... 9 7.6 EARLY WITHDRAWAL OF SUBJECTS ............................................................................................................... 10
7.6.1 When and How to Withdraw Subjects .................................................................................................. 10 7.6.2 Data Collection and Follow-up for Withdrawn Subjects ..................................................................... 11
8 STUDY DRUG/DEVICE ................................................................................................................................. 11
8.1 DESCRIPTION ................................................................................................................................................. 11 8.2 TREATMENT REGIMEN ................................................................................................................................... 11 8.3 METHOD FOR ASSIGNING SUBJECTS TO TREATMENT GROUPS ....................................................................... 11 8.4 PREPARATION AND ADMINISTRATION OF STUDY DRUG/IMPLANTATION OF STUDY DEVICE .......................... 12 8.5 SUBJECT COMPLIANCE MONITORING ............................................................................................................. 12 8.6 PRIOR AND CONCOMITANT THERAPY ............................................................................................................ 12 8.7 PACKAGING.................................................................................................................................................... 13 8.8 BLINDING OF STUDY DRUG/DEVICE .............................................................................................................. 13 8.9 RECEIVING, STORAGE, DISPENSING AND RETURN .......................................................................................... 13
8.9.1 Receipt of Drug Supplies/Device ......................................................................................................... 13 8.9.2 Storage ................................................................................................................................................. 13 8.9.3 Dispensing of Study Drug/Device ........................................................................................................ 13 8.9.4 Return or Destruction of Study Drug/Device ....................................................................................... 13
9 STUDY PROCEDURES .................................................................................................................................. 13
10 RISKS TO SUBJECTS .................................................................................................................................... 16
11 POTENTIAL BENEFIT TO SUBJECTS ...................................................................................................... 17
12 RESEARCH RELATED HARM/INJURY .................................................................................................... 17
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13 PROVISIONS TO PROTECT PRIVACY INTERESTS OF SUBJECTS .................................................. 18
14 STATISTICAL PLAN ..................................................................................................................................... 18
15 SAFETY AND ADVERSE EVENTS ............................................................................................................. 20
15.1 DEFINITIONS .............................................................................................................................................. 20 15.2 RECORDING OF ADVERSE EVENTS............................................................................................................. 21 15.3 REPORTING OF SERIOUS ADVERSE EVENTS ............................................................................................... 22
15.3.1 Study Sponsor Notification by Investigator ..................................................................................... 22 15.3.2 EC/IRB Notification by Investigator ............................................................................................... 22 15.3.3 FDA Notification by Sponsor ............................................................ Error! Bookmark not defined.
15.4 UNBLINDING PROCEDURES........................................................................................................................ 22 15.5 STOPPING RULES ....................................................................................................................................... 22 15.6 MEDICAL MONITORING ............................................................................................................................. 22 15.7 DATA AND SAFETY MONITORING .............................................................................................................. 23
15.7.1 Data and Safety Monitoring Plan ................................................................................................... 23 15.7.2 Internal Data and Safety Monitoring Board ..................................... Error! Bookmark not defined. 15.7.3 Independent Data and Safety Monitoring Board .............................. Error! Bookmark not defined.
16 DATA HANDLING AND RECORD KEEPING .......................................................................................... 24
16.1 CONFIDENTIALITY ..................................................................................................................................... 24 16.2 SOURCE DOCUMENTS ................................................................................................................................ 24 16.3 CASE REPORT FORMS ................................................................................................................................ 24 16.4 RECORDS RETENTION ................................................................................................................................ 24
17 STUDY MONITORING, AUDITING, AND INSPECTING ....................................................................... 24
17.1 STUDY MONITORING PLAN ....................................................................................................................... 24 17.2 AUDITING AND INSPECTING ....................................................................................................................... 25
19 STUDY FINANCES ......................................................................................................................................... 25
19.1 FUNDING SOURCE ..................................................................................................................................... 25 19.2 CONFLICT OF INTEREST ............................................................................................................................. 25 19.3 SUBJECT STIPENDS OR PAYMENTS ...................................................... ERROR! BOOKMARK NOT DEFINED.
20 PUBLICATION PLAN .................................................................................................................................... 26
21 REFERENCES .................................................................................. ERROR! BOOKMARK NOT DEFINED.
infarction. Descriptive statistics (n, mean, median, standard deviation, IQR, frequencies and
percentages) will be used to describe the demographic and clinical characteristics of the
whole sample.
For Aim 1, sensitivity, specificity, PPV, and NPV will be computed using the ICA result as the
‘true’ flow-limiting obstructive CAD status and the CTTA+CT-FFR test result as the ‘test’
status. Exact binomial 95% confidence intervals will be computed.
For Aim 2, inter- and intra-observer reliability for the CTTA and CTTA+CT-FFR tests will be
assessed using Cohen’s Kappa coefficient. Dependent Kappa coefficients will be compared
using a method developed by Donner et al .
For Aim 3, a survival analysis regression model will be carried out to determine which risk
factors are associated with “time-to-return visit”. Proposed factors will include age, sex,
race, diabetes, hyperlipidemia, hypertension, active smoking and smoking history, family
history of premature heart disease, obesity, and the number of cardiac risk factors present. In
addition we will consider adding whether the admission was surgical or medical, and the MS
or AP DRG case weight as a measure of severity.
Statistical Methods
Descriptive statistics (n, mean, median, standard deviation, IQR, frequencies and percentages)
will be used to describe the demographic and clinical characteristics of the whole sample.
For Aim 1, sensitivity, specificity, PPV, and NPV will be computed using the ICA result as the
‘true’ flow-limiting obstructive CAD status and the CTTA+CT-FFR test result as the ‘test’
status. Exact binomial 95% confidence intervals will be computed.
For Aim 2, inter- and intra-observer reliability for the CTTA and CTTA+CT-FFR tests will be
assessed using Cohen’s Kappa coefficient. Dependent Kappa coefficients will be compared
using a method developed by Donner et al .
For Aim 3, a survival analysis regression model will be carried out to determine which risk
factors are associated with “time-to-return visit”. Proposed factors will include age, sex,
race, diabetes, hyperlipidemia, hypertension, active smoking and smoking history, family
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history of premature heart disease, obesity, and the number of cardiac risk factors present. In
addition we will consider adding whether the admission was surgical or medical, and the MS
or AP DRG case weight as a measure of severity.
14.3 Subject Population(s) for Analysis
This is not a randomized trial. Data for all subjects who enroll in the study will be subject to
analysis, with appropriate adjustments for those who were unable to finish any part of the
study.
15 Safety and Adverse Events
15.1 Definitions
Adverse Event An adverse event (AE) is any symptom, sign, illness or experience that develops or worsens
in severity during the course of the study, as a result of study activities. Intercurrent illnesses
or injuries will be regarded as adverse events. Abnormal results of diagnostic procedures are
considered to be adverse events if the abnormality:
results in study withdrawal
is associated with a serious adverse event
is associated with clinical signs or symptoms
leads to additional treatment or to further diagnostic tests
is considered by the investigator to be of clinical significance
Serious Adverse Event Adverse events are classified as serious or non-serious. A serious adverse event is any AE
that is:
fatal
life-threatening
requires or prolongs hospital stay
results in persistent or significant disability or incapacity
an important medical event
Important medical events are those that may not be immediately life threatening, but are
clearly of major clinical significance. They may jeopardize the subject, and may require
intervention to prevent one of the other serious outcomes noted above. For example, drug
overdose or abuse, a seizure that did not result in in-patient hospitalization, or intensive
treatment of bronchospasm in an emergency department would typically be considered
serious.
All adverse events that do not meet any of the criteria for serious will be regarded as non-
serious adverse events.
Adverse Event Reporting Period
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The study period during which adverse events must be reported will be defined as the
period from the initiation of any study procedures to the end of the study treatment follow-
up. For this study, the study treatment follow-up is defined as 90 days following the last
administration of study treatment.
Preexisting Condition A preexisting condition is one that is present at the start of the study. Preexisting
conditions will be recorded as an adverse event if the errors in diagnosis cause less than
optimal treatment decisions.
General Physical Examination Findings At screening, any clinically significant abnormality will be recorded as a preexisting
condition. At the end of the study, any new clinically significant findings/abnormalities
that were not diagnosed through the study protocol will meet the definition of an adverse
event and will also be recorded and documented as an adverse event.
Post-study Adverse Event All unresolved adverse events should be followed by the investigator until the events are
resolved, the subject is lost to follow-up, or the adverse event is otherwise explained.
Hospitalization, Prolonged Hospitalization or Surgery Any adverse event that results in hospitalization or prolonged hospitalization will be
documented and reported as a serious adverse event. Any condition responsible for surgery
will be documented as an adverse event if the condition meets the criteria for and adverse
event. Neither the condition, hospitalization, prolonged hospitalization, nor surgery will be
reported as an adverse event in the following circumstances:
Hospitalization or prolonged hospitalization for diagnostic or elective surgical
procedures for a preexisting condition. Surgery will not be reported as an outcome
of an adverse event if the purpose of the surgery was elective or diagnostic and the
outcome was uneventful.
Hospitalization or prolonged hospitalization for therapy of the target disease of the
study, unless it is the result of inaccurate diagnostic information provided in the
study.
15.2 Recording of Adverse Events
At the follow-up contact with the subject, the study coordinator will seek information on adverse
events by specific questioning and, as appropriate, by referral to a study coordinator for
examination. Information on all adverse events should be recorded immediately in the source
document, and also in the appropriate adverse event module of the case report form (CRF). All
clearly related signs, symptoms, and abnormal diagnostic procedures results should recorded in
the source document, though should be grouped under one diagnosis.
All adverse events occurring during the study period will be recorded. The clinical course of
each event should be followed until resolution, stabilization, or until it has been determined that
the study treatment or participation is not the cause. Serious adverse events that are still ongoing
at the end of the study period will be followed up to determine the final outcome. Any serious
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adverse event that occurs after the study period and is considered to be possibly related to the
study treatment or study participation will be recorded and reported immediately.
15.3 Reporting of Serious Adverse Events
15.3.1 Study Sponsor Notification by Investigator
This is an investigator initiated trail funded by a charitable contribution from a grateful patient. There is no study sponsor outside of Northwell Health.
15.3.2 EC/IRB Notification by Investigator
Reports of all serious adverse events (including follow-up information) will be submitted
to the EC/IRB according to their policies. Copies of each report and documentation of
EC/IRB notification and receipt will be kept in the Clinical Investigator’s binder.
15.4 Unblinding Procedures
This is not a blinded clinical trial. Blinding in this study will not affect patient outcome, and,
therefore, no unblinding is necessary. Cardiologists will interpret CCTA scans without access
to FFR results. This is standard of care, and the interpretation will be necessary to determine
which cases should be sent for FFR. The FFR is a computerized procedure. At the time the
procedure is run, the computer operator will not know the exact level of obstruction
documented by the cardiologist. This information is irrelevant to the operations of the
computerized procedure and will not change the outcome of the CT-FFR test or the follow up
patient care.
15.5 Stopping Rules
This study is low risk to patients, because essentially, it requires the use of protocols that are
currently in place and represent standard of care. There may be a few instances in which a
Cardiac Catheterization might be recommended for a patient who would not have received
one if not a study participant. If the patient’s cardiologist documents concern regarding
patient safety if a Cardiac Catheterization were to be performed, the procedure will be
discontinued.
15.6 Medical Monitoring
It is the responsibility of the Principal Investigator to oversee the safety of the study at his/her site.
This safety monitoring will include careful assessment and appropriate reporting of adverse events
as noted above, as well as the construction and implementation of a site data and safety-monitoring
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plan (see section 17 Auditing, Monitoring and Inspecting). Medical monitoring will include a
regular assessment of the number and type of serious adverse events.
15.7 Data and Safety Monitoring
Only one of the following three sections needs to be included in the protocol.
15.7.1 Data and Safety Monitoring Plan
Michael Kim, M.D. will conduct data safety monitoring for the study.
His role as Director of the Cardiac Catheterization program at lenox Hill Hospital makes him
the most appropriate person to review the study safety, because he will have the most
complete information on the cardiovascular condition of the patient, and the patients response
to invasive ICA, the primary study activity that has potential to influence patient safety.
The expected types of events that will be monitored include major adverse cardiac events
resulting from any Cardiac Catheterization, Percutaneous Coronary Intervention, or
Coronary Artery Bypass Graft in a patient who, if not enrolled in the study, would not have
received Cardiac Cath or invasive treatments. In addition, the monitor will review any
medical complications for these subjects. The study coordinator will refer all patients who
received Cardiac Cath, who would not have otherwise have received it if not part of the study.
The monitor will review whether adverse events were the result of the study activity or related
to procedures provided as part of standard of care, and whether safety policies and
procedures were followed within one week of the all referrals. The monitor will present any
recommendations for changes to the study resulting from the review to the study PI.
The monitor will conduct reviews as near as possible to the time the event was identified and
always within a month of the identification of the event.
We do not expect to need to alter or interrupt the study design, because of the very low risk
nature of the study. However, any unexpected safety events related to the study design will be
carefully reviewed by the Safety Monitor and the study PI and reported to the IRB and
Hospital quality assurance. If improvement in patient safety can be made by changing the
design, immediate consideration will be given to the prospective change.
There are no issues with toxicity in this study.
If the study should be temporarily suspended, we will report this to the IRB, Clinical
trials.gov, and to HeartFlow.
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16 Data Handling and Record Keeping
16.1 Confidentiality
Information about study subjects will be kept confidential and managed according to the
requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Those regulations require a signed subject authorization informing the subject of the following:
What protected health information (PHI) will be collected from subjects in this study
Who will have access to that information and why
Who will use or disclose that information
The rights of a research subject to revoke their authorization for use of their PHI.
In the event that a subject revokes authorization to collect or use PHI, the investigator, by
regulation, retains the ability to use all information collected prior to the revocation of subject
authorization. For subjects that have revoked authorization to collect or use PHI, attempts
should be made to obtain permission to collect at least vital status (i.e. that the subject is alive) at
the end of their scheduled study period.
16.2 Source Documents
Source data is all information, original records of clinical findings, observations, or other
activities in the clinical trial necessary for the reconstruction and evaluation of the trial. Source
data are contained in source documents Examples of these original documents, and data records
include: hospital records, clinical and office charts, CCTA and FFR results, notes, memoranda,
pharmacy dispensing records, recorded data from automated instruments, copies or transcriptions
certified after verification as being accurate and complete, microfiches, photographic negatives,
microfilm or magnetic media, x-rays, subject files, and records kept at the pharmacy, at the
laboratories, and at medico-technical departments involved in the clinical trial.
16.3 Case Report Forms
The study case report form (CRF) is the primary data collection instrument for the study. All
data requested on the CRF must be recorded. All missing data must be explained. If a space on
the CRF is left blank because the procedure was not done or the question was not asked, the study
coordinator will indicate this by writing “N/D”. If the item is not applicable to the individual case,
the study coordinator will indicate this by writing write “N/A”. All entries will be maintained on
RedCap, this includes the retrospective study as well.
16.4 Records Retention
The investigator will be responsible to retain study essential documents for at least 2 years after
the last publication of initial findings.
17 Study Monitoring, Auditing, and Inspecting
17.1 Study Monitoring Plan
This is a private study. No external monitor has been assigned.
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Auditing and Inspecting:
The investigator will permit study-related monitoring, audits, and inspections by the EC/IRB,
government regulatory bodies, and University compliance and quality assurance groups of all
study related documents (e.g. source documents, regulatory documents, data collection
instruments, study data etc.). The investigator will ensure the capability for inspections of