The Optimal Imaging Strategy for Patients With Stable Chest Pain: A Cost-Effectiveness Analysis

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; and M.G. Myriam Hunink, MD, PhD

Ann Intern Med. 2015;162(7):474-484. doi:10.7326/M14-0027

Background: The optimal imaging strategy for patients with stable chest pain is uncertain.

Objective: To determine the cost-effectiveness of different imaging strategies for patients with stable chest pain.

Design: Microsimulation state-transition model.

Data Sources: Published literature.

Target Population: 60-year-old patients with a low to intermediate probability of coronary artery disease (CAD).

Time Horizon: Lifetime.

Perspective: The United States, the United Kingdom, and the Netherlands.

Intervention: Coronary computed tomography (CT) angiography, cardiac stress magnetic resonance imaging, stress single-photon emission CT, and stress echocardiography.

Outcome Measures: Lifetime costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios.

Results of Base-Case Analysis: 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 of Sensitivity Analysis: Results were sensitive to changes in the probability of CAD and assumptions about false-positive results.

Limitations: 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.

Conclusion: 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.