Key result
An initial strategy of stress echocardiography for patients with high pretest probability of CAD significantly reduced costs compared to hypothetical direct angiography (£654 vs £1400, P<0.001).
Why the study?
Does an initial stress echocardiography strategy reduce costs and maintain safety compared to direct invasive coronary angiography in patients with high pretest probability of CAD?
Observational (n=257)
Does an initial stress echocardiography strategy reduce costs and maintain safety compared to direct invasive coronary angiography in patients with high pretest probability of CAD?
An initial stress echocardiography strategy for patients with high pretest probability of CAD significantly reduces costs compared to direct invasive angiography, with a low rate of adverse events.
Initial stress echocardiography was associated with lower costs in high-probability CAD; leaves open safety versus direct angiography and requires randomized confirmation.
OBJECTIVE: In this study, we assess the clinical and cost-effectiveness of stress echocardiography (SE), as well as the place of SE in patients with high pretest probability (PTP) of coronary artery disease (CAD). METHODS: We investigated 257 patients with no history of CAD, who underwent SE, and they had a PTP risk score >61% (high PTP). According to the National Institute for Health and Care Excellence guidance (NICE CG95, 2010), these patients should be investigated directly with an invasive coronary angiogram (ICA). We investigated those patients with SE initially and then with ICA when appropriate. Follow-up data with regard to Major Adverse Cardiac and Cerebrovascular Events (MACCE, defined as cardiovascular mortality, cerebrovascular accident (CVA), myocardial infarction (MI) and late revascularisation for acute coronary syndrome/unstable angina) were recorded for a period of 12 months following the SE. The tariff for SE and ICA is £300 and £1400, respectively. RESULTS: 106 patients had a positive SE (41.2%) and 61 of them (57.5%) had further investigation with ICA. 15 (24.6%) of these patients were revascularised. The average cost per patient for investigations was £654.09. If NICE guidance had been followed, the cost would have been significantly higher at £1400 (p<0.001). Overall, 5 MACCE (2.0%) were recorded; 4 (3.8%) in the group of positive SE (2 CVAs and 2 MIs) and 1 (0.7%) in the group of negative SE (1 CVA). There was no MI and no need for revascularisation in the negative SE group. CONCLUSION: Our approach to investigate patients who present with de novo chest pain and high PTP, with SE initially and subsequently with ICA when appropriate, reduces the cost significantly (£745.91 per patient) with a very low rate of MACCE. However, this study is underpowered to assess safety of SE.
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Papachristidis et al. (2017) conducted an observational in High pretest probability of coronary artery disease (n=257). Stress echocardiography (SE) vs. Direct invasive coronary angiogram (ICA) (hypothetical per NICE guidance) was evaluated on Average cost per patient for investigations (p=<0.001). An initial strategy of stress echocardiography for patients with high pretest probability of CAD significantly reduced costs compared to hypothetical direct angiography (£654 vs £1400, P<0.001).
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