Cost-effectiveness of diagnostic strategies for patients with chest pain

Background: Many noninvasive tests exist to determine whether patients shou ld undergo coronary angiography. The routine use of coronary angiography wi thout previous noninvasive testing is typically not advocated. Objective: To determine the cost-effectiveness of diagnostic strategies for patients with chest pain. Design: Cost-effectiveness analysis, Data Sources: Published data. Target Population: Patients who present with chest pain, have no history of myocardial infarction, and are able to perform an exercise stress test. Time Horizon: Lifetime. Perspective: Societal. Interventions: No testing, exercise electrocardiography, exercise echocardi ography, exercise single-photon emission computed tomography (SPECT), and c oronary angiography alone. Outcome Measures: quality-adjusted life expectancy, lifetime cost, and incr emental cost-effectiveness. Results of Base-Case Analysis: The incremental cost-effectiveness ratio of routine coronary angiography compared with exercise echocardiography was $3 6 400 per quality-adjusted life-year (QALY) saved for 55-year-old men with typical angina. For 55-year-old men with atypical angina, exercise echocard iography compared with exercise electrocardiography cost $41 900 per QALY s aved. If adequate exercise echocardiography was not available, exercise SPE CT cost $54 800 per QALY saved compared with exercise electrocardiography f or these patients. For 55-year-old men with nonspecific chest pain, the inc remental cost-effectiveness ratio of exercise electrocardiography compared with no testing was $57 700 per QALY saved. Results of Sensitivity Analysis: On the basis of a probabilistic sensitivit y analysis, there is a 75% chance that exercise echocardiography costs less than $50 900 per QALY saved for 55-year-old men with atypical angina. Conclusions: Exercise electrocardiography or exercise echocardiography resu lted in reasonable cost-effectiveness ratios for patients at mild to modera te risk for coronary artery disease in terms of age, sex, and type of chest pain. Coronary angiography without previous noninvasive testing resulted i n reasonable cost-effectiveness ratios for patients with a high pretest pro bability of coronary artery disease.