Optimal Imaging Strategy for Patients With Stable Chest Pain

Study Questions:

What is the cost-effectiveness of different imaging strategies for patients with stable chest pain?

Methods:

This was a microsimulation state-transition model designed to evaluate the comparative effectiveness and costs of coronary computed tomography (CT) angiography and cardiac stress imaging. The target population was 60-year-old patients with a low to intermediate probability of coronary artery disease (CAD). The following diagnostic strategies were modeled: no imaging, coronary CT angiography, cardiac stress imaging, coronary CT angiography with positive results followed by cardiac stress imaging (cardiac stress magnetic resonance imaging, stress single-photon emission CT, and stress echocardiography), and direct catheter-based coronary angiography. The model was analyzed from the perspective of the United Kingdom (UK), the United States, and the Netherlands. Outcome measures were lifetime costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios.

Results:

The strategy that maximized QALYs and was cost-effective in the United States and the Netherlands began with coronary CT angiography, continued with cardiac stress imaging if angiography found at least 50% stenosis in at least one coronary artery, and ended with catheter-based angiography if stress imaging induced ischemia of any severity. For UK men, the preferred strategy was optimal medical therapy without catheter-based angiography if coronary CT angiography found only moderate CAD or stress imaging induced only mild ischemia. For UK women, the preferred strategy was stress echocardiography followed by catheter-based angiography if echocardiography induced mild or moderate ischemia.

Conclusions:

The authors concluded that in 60-year-old patients with nonacute chest pain and a low to intermediate probability of CAD, coronary CT angiography as a triage test before cardiac stress imaging is cost-effective.

Perspective:

This is an interesting and informative cost-effectiveness analysis of different imaging strategies for patients with stable chest pain. Recent data have suggested that coronary CT angiography is a valid strategy for the evaluation of patients with chest pain. This analysis adds further support to a strategy of coronary CT angiography upstream to cardiac stress imaging. Of course and as the authors acknowledge, the choice of cardiac stress imaging modality may be influenced by multiple factors, including local expertise and availability.

Clinical Topics: Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Computed Tomography, Echocardiography/Ultrasound, Magnetic Resonance Imaging, Nuclear Imaging

Keywords: Chest Pain, Constriction, Pathologic, Coronary Angiography, Coronary Artery Disease, Cost-Benefit Analysis, Echocardiography, Stress, Myocardial Ischemia, Magnetic Resonance Imaging, Outcome Assessment (Health Care), Quality-Adjusted Life Years, Tomography, Emission-Computed, Single-Photon


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