Alexander Goehler MD, PhD, Presenter: Nothing to Disclose

James Bayley, Abstract Co-Author: Nothing to Disclose

Julia EH Nolte, Abstract Co-Author: Nothing to Disclose

Thomas Joseph Brady MD, Abstract Co-Author: Grant, Siemens AG

G. Scott Gazelle MD, MPH, PhD, Abstract Co-Author: Consultant, General Electric Company Consultant, Marval Biosciences Inc

Udo Hoffmann MD, Abstract Co-Author: Nothing to Disclose

Coronary CT angiography (CTA) as a technique has excellent test characteristics for the detection of significant coronary stenosis and nonobstructive disease and has evolved as an alternative to functional testing in the initial assessment of patients with stable chest pain syndrome. Our objective was to evaluate clinical outcomes, costs, and cost-effectiveness of CTA, stress-EKG, stress-echocardiography and SPECT as well as strategies combining CTA and functional testing modalities.

We developed a Markov model to simulate incidence and progression of CAD (non-obstructive and obstructive) as a function of patient age, gender and cardiac risk profile. Risk for mortality depended on patient’s demographics as well as CVD and treatment status. We compared (1) preventive treatment (SOC) to (2) CTA (CTA), (3) stress-EKG/stress-echo/SPECT (in 20%, 50%, and 30% of the cases) (FT), (4) FT followed by CTA if FT positive or indeterminate (FT-CTA), (5) CT followed by FT if CTA positive or indeterminate (CTA-FT).

In our base case population (males, 50 years, intermediate FRS for CHD) the prevalence of CAD was estimated at 53% (13% obstructive). FT correctly identified 13% (10%) at $852/patient; CTA 45% (12%), CTA-FT 49% (10%), FT-CTA 17% (9%) at $815, $726, and $667 per patient, respectively. The model predicted an average remaining life expectancy of 21.98 quality adjusted life years (QALY) for SOC and 22.25, 22.39, 22.27 and 22.25 QALYs for FT, CTA, CTA-FT, and FT-CTA, respectively. This resulted in an incremental cost-effectiveness ratio (ICER) of $13,900/QALY for FT compared to SOC, and of $30,000/QALY for CTA vs. FT; CTA-FT and FT-CTA were both dominated. Considering no treatment effect on progression of non-obstructive CAD decreased life expectancy between 0.01 – 0.11 QALYS depending the percentage of diagnosed non-obstructive CAD in that strategy; however, CTA remained the most effective strategy with an ICER of $28,600/QALY (figure).

Preliminary analyses indicate that CTA is cost-effective compared to functional testing as an initial evaluation of patients with chronic chest pain. These results are independent of treatment effect on non-obstructive CAD.

These data provide initial evidence that coronary CTA is a cost effective alternative to functional testing as an initial diagnostic test in the evaluation of patients with stable chest pain syndrome.

Goehler, A, Bayley, J, Nolte, J, Brady, T, Gazelle, G, Hoffmann, U, Comparative Effectiveness and Cost-effectiveness of Initial Anatomic vs Functional Testing in Patients with Stable Chronic Chest Pain Syndrome.  Radiological Society of North America 2011 Scientific Assembly and Annual Meeting, November 26 - December 2, 2011 ,Chicago IL. http://archive.rsna.org/2011/11015618.html