Tessa S.S. Genders, MD, PhD; Steffen E. Petersen, MD, DPhil, MPH; Francesca Pugliese, MD, PhD; Amardeep G. Dastidar, MBBS; Kirsten E. Fleischmann, MD, MPH; Koen Nieman, MD, PhD; M.G. Myriam Hunink, MD, PhD
Note: Dr. Hunink had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Acknowledgment: The authors thank Sotiris Antoniou, consultant pharmacist with the Department of Cardiovascular Medicine at Barts Health NHS Trust, for the useful discussions about costs and medication use.
Financial Support: By a Health Care Efficiency grant from the Erasmus University Medical Center. Drs. Petersen and Pugliese were directly funded by the National Institute for Health Research Cardiovascular Biomedical Research Unit at Barts. Dr. Dastidar received direct funding from Barts and The London Charity (437/1412). Dr. Fleischmann was directly funded by a grant from the National Institutes of Health (National Heart, Lung, and Blood Institute award R21HL112255).
Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-0027.
Reproducible Research Statement:Study protocol, statistical code, and data set: The authors have provided extensive detail about the structure of the model, the assumptions made, and the input data that will allow reproduction of the decision model in the Appendix. They are willing to share the decision model in the context of a collaborative project. Dr. Hunink may be contacted for this purpose (e-mail, m.hunink@erasmusmc.nl).
Requests for Single Reprints: M.G. Myriam Hunink, MD, PhD, Departments of Epidemiology and Radiology, Erasmus University Medical Center, PO Box 2040, 3000 CA Rotterdam, the Netherlands; e-mail, m.hunink@erasmusmc.nl.
Current Author Addresses: Dr. Genders: Department of Epidemiology, Erasmus University Medical Center, PO Box 2040, 3000 CA Rotterdam, the Netherlands.
Drs. Petersen and Pugliese and Mr. Dastidar: Centre for Advanced Cardiovascular Imaging, William Harvey Research Institute, NIHR Cardiovascular Biomedical Research Unit at Barts, The London Chest Hospital, Bonner Road, London EC2 9JX, United Kingdom.
Dr. Fleischmann: UCSF School of Medicine, Box 0124, 505 Parnassus Avenue, San Francisco, CA 94143-0124.
Dr. Nieman: Department of Cardiology, Erasmus University Medical Center, PO Box 2040, 3000 CA Rotterdam, the Netherlands.
Dr. Hunink: Departments of Epidemiology and Radiology, Erasmus University Medical Center, PO Box 2040, 3000 CA Rotterdam, the Netherlands.
Author Contributions: Conception and design: T.S.S. Genders, S.E. Petersen, K.E. Fleischmann, K. Nieman, M.G.M. Hunink.
Analysis and interpretation of the data: T.S.S. Genders, S.E. Petersen, M.G.M. Hunink.
Drafting of the article: T.S.S. Genders, S.E. Petersen.
Critical revision of the article for important intellectual content: T.S.S. Genders, S.E. Petersen, F. Pugliese, A.G. Dastidar, K.E. Fleischmann, K. Nieman, M.G.M. Hunink.
Final approval of the article: T.S.S. Genders, S.E. Petersen, F. Pugliese, A.G. Dastidar, K.E. Fleischmann, K. Nieman, M.G.M. Hunink.
Provision of study materials or patients: T.S.S. Genders, S.E. Petersen, F. Pugliese.
Statistical expertise: T.S.S. Genders, S.E. Petersen, M.G.M. Hunink.
Administrative, technical, or logistic support: T.S.S. Genders, S.E. Petersen, M.G.M. Hunink.
Collection and assembly of data: T.S.S. Genders, S.E. Petersen, F. Pugliese, A.G. Dastidar.
The optimal imaging strategy for patients with stable chest pain is uncertain.
To determine the cost-effectiveness of different imaging strategies for patients with stable chest pain.
Microsimulation state-transition model.
Published literature.
60-year-old patients with a low to intermediate probability of coronary artery disease (CAD).
Lifetime.
The United States, the United Kingdom, and the Netherlands.
Coronary computed tomography (CT) angiography, cardiac stress magnetic resonance imaging, stress single-photon emission CT, and stress echocardiography.
Lifetime costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios.
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 1 coronary artery, and ended with catheter-based coronary angiography if stress imaging induced ischemia of any severity. For U.K. men, the preferred strategy was optimal medical therapy without catheter-based coronary angiography if coronary CT angiography found only moderate CAD or stress imaging induced only mild ischemia. In these strategies, stress echocardiography was consistently more effective and less expensive than other stress imaging tests. For U.K. women, the optimal strategy was stress echocardiography followed by catheter-based coronary angiography if echocardiography induced mild or moderate ischemia.
Results were sensitive to changes in the probability of CAD and assumptions about false-positive results.
All cardiac stress imaging tests were assumed to be available. Exercise electrocardiography was included only in a sensitivity analysis. Differences in QALYs among strategies were small.
Coronary CT angiography is a cost-effective triage test for 60-year-old patients who have nonacute chest pain and a low to intermediate probability of CAD.
Erasmus University Medical Center.
Genders TS, Petersen SE, Pugliese F, et al. The Optimal Imaging Strategy for Patients With Stable Chest Pain: A Cost-Effectiveness Analysis. Ann Intern Med. 2015;162:474–484. doi: 10.7326/M14-0027
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© 2019
Published: Ann Intern Med. 2015;162(7):474-484.
DOI: 10.7326/M14-0027
Cardiac Diagnosis and Imaging, Cardiology, High Value Care.
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