Saurabh Jha MD, Presenter: Research grant, General Electric Company

Study examines which test used in isolation or in combination is the most cost effective strategy in patients suspected of chronic stable angina.

A combination of decision tree and Markov model was used to capture the diagnostic and therapeutic pathway and natural history in patients suspected of chronic stable angina. Lifetime costs and quality associated life years were projected.  Secondary outcomes included radiation dose exposure and proportion of negative catheter angiograms. The base case included 55 year old female with atypical chest pain and a 55 year old male with atypical chest pain representing 30 % and 70 % pre-test probability, respectively. Catheter angiography was assumed to be the gold standard for the diagnosis of coronary artery disease. Extensive sensitivity analyses were performed.

The strategy of straight catheter angiography without a preceding imaging or other diagnostic test was both the costliest and most effective. Of all the imaging modalities, cardiac CT yielded the lowest incremental cost effectiveness ratio and was thus the most cost effective imaging modality used in isolation. Cardiac PET was dominated by cardiac CT. Extended dominance was noted of stress echo, dobutamine stress MRI, myocardial perfusion scintigraphy and adenosine stress MRI by cardiac CT. Adenosine stress MRI was costlier and more effective than myocardial perfusion scintigraphy. Sensitivity analysis revealed that effectiveness is driven by test sensitivity and non-diagnostic rate of the test. The ranking of the tests in terms of costs and QALYs seemed to be independent of costs and mortality of treatment and the probability of being revascularized.  

For an imaging modality to be used in isolation as the first test in patients suspected of chronic stable angina with intermediate pre-test probability cardiac CT is the most cost effective.

The use of appropriate imaging modality in chronic stable angina will reduce costs and the rate of negative catheter angiograms in patients with chronic stable angina.

Jha, S, Cost-effectiveness of Various Diagnostic Strategies in Patients with Symptoms Suggestive of Chronic Ischemic Heart Disease.  Radiological Society of North America 2011 Scientific Assembly and Annual Meeting, November 26 - December 2, 2011 ,Chicago IL. http://archive.rsna.org/2011/11015263.html