December 21, 1999

Emergency Department Triage Strategies for Acute Chest Pain Using Creatine Kinase–MB and Troponin I Assays: A Cost-Effectiveness Analysis

CPCarísi Anne PolanczykGeneral / Preventive / Lipids KKKaren M. KuntzUniversity of Minnesota DSDavid B. SacksNational Institutes of Health

Structured PICO

What is the most cost-effective triage strategy using cardiac markers and noninvasive tests for patients admitted with acute chest pain?

Population

1066 patients admitted with acute chest pain (prospective data) and data from published literature

Intervention

Triage strategies using creatine kinase (CK)-MB mass assay alone, CK-MB followed by troponin I, both assays, or troponin I alone, with or without early exercise testing

Comparator

Alternative triage strategies

Outcome

Lifetime cost, life expectancy (in years), and incremental cost-effectiveness

Measurement of CK-MB mass plus early exercise testing is a cost-effective initial strategy for younger patients with low-to-moderate MI probability, while troponin I is cost-effective as a second test in higher-risk subsets.

Abstract

BACKGROUND: Evaluation of acute chest pain is highly variable. OBJECTIVE: To evaluate the cost-effectiveness of strategies using cardiac markers and noninvasive tests for myocardial ischemia. DESIGN: Cost-effectiveness analysis. DATA SOURCES: Prospective data from 1066 patients with chest pain and from the published literature. TARGET POPULATION: Patients admitted with acute chest pain. TIME HORIZON: Lifetime. PERSPECTIVE: Societal. INTERVENTIONS: Creatine kinase (CK) -MB mass assay alone; CK-MB mass assay followed by cardiac troponin I assay if the CK-MB value is normal; CK-MB mass assay followed by troponin I assay if the CK-MB value is normal and electrocardiography shows ischemic changes; both CK-MB mass and troponin I assays; and troponin I assay alone. These strategies were evaluated alone or in combination with early exercise testing. OUTCOME MEASURES: Lifetime cost, life expectancy (in years), and incremental cost-effectiveness. RESULTS OF BASE-CASE ANALYSIS: For patients 55 to 64 years of age, measurement of CK-MB mass followed by exercise testing in appropriate patients was the most competitive strategy (43000 per year of life saved). Measurement of CK-MB mass followed by troponin I measurement had an incremental cost-effectiveness ratio of 47400 per year of life saved for patients 65 to 74 years of age; it was also the most cost-effective strategy when early exercise testing could not be performed, CK-MB values were normal, and ischemic changes were seen on electrocardiography. RESULTS OF SENSITIVITY ANALYSIS: Results were influenced by age, probability of myocardial infarction, and medical costs. CONCLUSIONS: Measurement of CK-MB mass plus early exercise testing is a cost-effective initial strategy for younger patients and those with a low to moderate probability of myocardial infarction. Troponin I measurement can be a cost-effective second test in higher-risk subsets of patients if the CK-MB level is normal and early exercise testing is not an option.

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