Abstract
AimThis study aimed at evaluating the cost-effectiveness of different non-invasive imaging-guided strategies for the diagnosis of obstructive coronary artery disease (CAD) in a European population of patients from the Evaluation of Integrated Cardiac Imaging in Ischemic Heart Disease (EVINCI) study.Methods and resultsCost-effectiveness analysis was performed in 350 patients (209 males, mean age 59 ± 9 years) with symptoms of suspected stable CAD undergoing computed tomography coronary angiography (CTCA) and at least one cardiac imaging stress-test prior to invasive coronary angiography (ICA) and in whom imaging exams were analysed at dedicated core laboratories. Stand-alone stress-tests or combined non-invasive strategies, when the first exam was uncertain, were compared. The diagnostic end-point was obstructive CAD defined as > 50% stenosis at quantitative ICA in the left main or at least one major coronary vessel. Effectiveness was defined as the percentage of correct diagnosis (cd) and costs were calculated using country-specific reimbursements. Incremental cost-effectiveness ratios (ICERs) were obtained using per-patient data and considering “no-imaging” as reference. The overall prevalence of obstructive CAD was 28%. Strategies combining CTCA followed by stress ECHO, SPECT, PET, or stress CMR followed by CTCA, were all cost-effective. ICERs values indicated cost saving from − 969€/cd for CMR-CTCA to − 1490€/cd for CTCA-PET, − 3092€/cd for CTCA-SPECT and − 3776€/cd for CTCA-ECHO. Similarly when considering early revascularization as effectiveness measure.ConclusionIn patients with suspected stable CAD and low prevalence of disease, combined non-invasive strategies with CTCA and stress-imaging are cost-effective as gatekeepers to ICA and to select candidates for early revascularization.
Highlights
Available guidelines for symptomatic patients with suspected stable coronary artery disease (CAD) recommend diagnostic flow-charts using computed tomography coronary angiography (CTCA) as the first-line investigation in all patients [1] or stress imaging and CTCA according to the pre-test probability (PTP) [2]
The economic evaluation of the EVINCI study indicates that non-invasive strategies combining CTCA with stressimaging, in the case of inconclusive results of the first test, are cost-effective diagnostic options in patients with stable chest pain symptoms and low prevalence of obstructive CAD
CTCA as first test followed by stress ECHO, SPECT, positron emission tomography (PET) or stress cardiac magnetic resonance (CMR) as first test followed by CTCA were associated with overall reduced costs and higher diagnostic efficacy, as compared with a “no-imaging” strategy, selfstanding single non-invasive tests or other combinations
Summary
Available guidelines for symptomatic patients with suspected stable coronary artery disease (CAD) recommend diagnostic flow-charts using computed tomography coronary angiography (CTCA) as the first-line investigation in all patients [1] or stress imaging and CTCA according to the pre-test probability (PTP) [2]. Additional non-invasive testing is considered in the case of uncertain results of the first test [1, 2]. Despite this and in view of the wide range of valid available options, the selection of non-invasive imaging in clinical practice may be influenced by factors not included in guidelines [2]. Evidence suggests that the cost of diagnostic imaging has nearly doubled in the past few decades and there is a wide variation among countries, due to different practice, healthcare and reimbursement systems [4, 5]; the rapid spread of cardiovascular disease in Europe and worldwide, combined with the increasing use of testing via non-invasive approaches, suggest the need for guidance in appropriate decision making
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