COST-EFFECTIVENESS OF ROUTINE CORONARY ANGIOGRAPHY AFTER ACUTE MYOCARDIAL-INFARCTION

Background Coronary angiography is indicated for many patients after a cute myocardial infarction (AMI). There are a number of subgroups of A MI patients, however, for whom the indication for coronary angiography is not well established. Methods and Results We developed a decision- analytic model for AMI in representative patient subgroups based on re levant clinical characteristics. The model estimates quality-adjusted life expectancy and direct lifetime costs for two strategies: coronary angiography and treatment guided by its results versus initial medica l therapy without angiography. Decision tree chance node probabilities were estimated with the use of pooled data from randomized clinical t rials and other relevant literature, costs were estimated with the use of the Medicare Part A database, and quality of life adjustments were derived from a survey of 1051 patients who had had a recent AMI. In o ur analysis, incremental cost-effectiveness ratios for coronary angiog raphy and treatment guided by its result, compared with initial medica l therapy without angiography, ranged between $17 000 and >$1 million per quality-adjusted year of life gained. Patient subgroups with sever e postinfarction angina or a strongly positive exercise tolerance test (ETT) typically had cost-effectiveness ratios of <$50 000 per quality -adjusted year of life gained. In addition, most patient subgroups wit h a prior AMI had cost-effectiveness ratios of <$50 000 per qualify-ad justed year of life gained, even with a negative ETT result. Conclusio ns In many patient subgroups after AMI, the cost-effectiveness of rout ine coronary angiography and treatment guided by its results compares favorably with other treatment strategies for coronary heart disease.