Cost analysis of diagnostic testing for coronary artery disease in women with stable chest pain

Background. Seven clinical sites compiled data from 4638 women who were ref erred directly to coronary angiography (catheterization-first strategy; n = 3375) or who underwent stress myocardial perfusion imaging (MPI) first (n = 1263) followed by coronary angiography if at least one reversible myocard ial perfusion abnormality was detected, The study examines the cost minimiz ation potential of these available invasive and noninvasive diagnostic stra tegies in women with chest pain. Methods and Results. Women in both groups were subclassified by the core la boratory as being at low (<0.15), intermediate (0.15 to 0.60), or high (>0. 60) pretest likelihood for corollary artery disease (CAD). Among the cathet erization-first patients, at least one coronary stenosis >70% was present i n 13% of low likelihood patients, 29% of intermediate likelihood patients, and 52% of patients with high CAD likelihood. Perfusion abnormality rates i n the MPI-first group were 23% in low likelihood patients, 27% in intermedi ate likelihood patients, and 34% in high CAD likelihood patients. Of the MP I-first subset, 50%, 55%, and 76%, respectively, underwent catheterization in at least one coronary stenosis >70%. Cardiac death rates ranged from 0.5 % to 2.2% in patients with CAD and did not differ from the 2 testing strate gies (P = not significant), The composite cost per patient of diagnostic te sting plus follow-up medical care over a period of 2.5 +/- 1.5 gears (calcu lated for both strategies from inflation-corrected Medicare charges, adjust ed for institutional cost-charge ratios) ranged from $2490 for patients wit h low likelihood to $3687 for patients with high likelihood with the cathet erization-first strategy and from $1587 to $2585 for patients undergoing MP I first (P < .01 between risk subsets and strategies). Conclusions. In women referred for diagnostic evaluation of stable chest pa in, MPI followed by selective coronary angiography in patients with at leas t 1 perfusion abnormality minimizes the near-term composite cost per patien t compared with a direct catheterization-first strategy, regardless of pret est CAD likelihood.