Economic analysis including long-term risks and costs of alternative diagnostic strategies to evaluate patients with chest pain

BACKGROUND: Diagnosis costs for cardiovascular disease waste a large amount of healthcare resources. The aim of the study is to evaluate the clinical and economic outcomes of alternative diagnostic strategies in low risk chest pain patients. METHODS: We evaluated direct and indirect downstream costs of 6 strategies: coronary angiography (CA) after positive troponin I or T (cTn-I or cTnT) (strategy 1) ; after positive exercise electrocardiography (ex-ECG) (strategy 2) ; after positive exercise echocardiography (ex-Echo) (strategy 3) ; after positive pharmacologic stress echocardiography (PhSE) (strategy 4) ; after positive myocardial exercise stress single-photon emission computed tomography with technetium Tc 99m sestamibi (ex-SPECT-Tc) (strategy 5) and direct CA (strategy 6). RESULTS: The predictive accuracy in correctly identifying the patients was 83, 1% for cTn-I, 87% for cTn-T, 85, 1% for ex-ECG, 93, 4% for ex-Echo, 98, 5% for PhSE, 89, 4% for ex-SPECT-Tc and 18, 7% for CA. The cost per patient correctly identified results 2. 051 for cTn-I, 2. 086 for cTn-T, 1. 890 for ex-ECG, 803 for ex-Echo, 533 for PhSE, 1. 521 for ex-SPECT-Tc (1. 634 including cost of extra risk of cancer) and 29. 673 for CA (29. 999 including cost of extra risk of cancer). The average relative cost-effectiveness of cardiac imaging compared with the PhSE equal to 1 (as a cost comparator), the relative cost of ex-Echo is 1. 5x, of a ex-SPECT-Tc is 3. 1x, of a ex-ECG is 3. 5x, of cTnI is x3. 8, of cTnT is x3. 9 and of a CA is 56. 3x. CONCLUSION: Stress echocardiography based strategies are cost-effective versus alternative imaging strategies and the risk and cost of radiation exposure is void.