Abstract
ObjectivesThe aim of this retrospective study was to determine cost-effectiveness of stress myocardial CT perfusion (CTP), coronary CT angiography (CTA), and the combination of both in suspected obstructive coronary artery disease (CAD) or in-stent restenosis (ISR) in patients with previous coronary stent implantation.MethodsA decision model based on Markov simulations estimated lifetime costs and quality-adjusted life years (QALYs) associated with CTA, CTP, and CTA + CTP. Model input parameters were obtained from published literature. Probabilistic sensitivity analysis was performed to evaluate overall model uncertainty. A single-variable deterministic sensitivity analysis evaluated the sensitivity of the results to plausible variations in model inputs. Cost-effectiveness was assessed based on a cost-effectiveness threshold of $100,000 per QALY.ResultsIn the base-case scenario with willingness to pay of $100,000 per QALY, CTA resulted in total costs of $47,013.87 and an expected effectiveness of 6.84 QALYs, whereas CTP resulted in total costs of $46,758.83 with 6.93 QALYs. CTA + CTP reached costs of $47,455.63 with 6.85 QALYs. Therefore, strategies CTA and CTA + CTP were dominated by CTP in the base-case scenario. Deterministic sensitivity analysis demonstrated robustness of the model to variations of diagnostic efficacy parameters and costs in a broad range. CTP was cost-effective in the majority of iterations in the probabilistic sensitivity analysis as compared with CTA.ConclusionsCTP is cost-effective for the detection of obstructive CAD or ISR in patients with previous stenting and therefore should be considered a feasible approach in daily clinical practice.Key Points• CTP provides added diagnostic value in patients with previous coronary stents.• CTP is a cost-effective method for the detection of obstructive CAD or ISR in patients with previous stenting.
Highlights
Until today, invasive fractional flow reserve (FFR) has been universally considered the reference standard in evaluating the hemodynamic relevance of obstructive coronary artery disease (CAD) [1, 2]
Coronary computed tomography angiography (CTA) is one of the most common cardiac imaging modalities and it is widely recognized for its diagnostic accuracy in the detection of CAD, especially in patients with a low pre-test probability for CAD [5, 6]
CT angiography (CTA) is not recommended in patients with prior coronary stenting [7], primarily due to beam hardening artifacts originating from metallic stent struts [8,9,10] and the high atherosclerotic burden in non-stented segments which often results in the overestimation of CAD severity [11]
Summary
Invasive fractional flow reserve (FFR) has been universally considered the reference standard in evaluating the hemodynamic relevance of obstructive coronary artery disease (CAD) [1, 2]. The role of cardiac imaging in evaluating CAD is steadily growing in importance [3], mainly owing to its non-invasive nature [4]. Coronary computed tomography angiography (CTA) is one of the most common cardiac imaging modalities and it is widely recognized for its diagnostic accuracy in the detection of CAD, especially in patients with a low pre-test probability for CAD [5, 6]. CTP has been repeatedly shown to improve diagnostic accuracy in the detection of obstructive CAD in general [12,13,14,15,16,17,18,19,20,21], and few studies have demonstrated the diagnostic value of CTP in patients with previous coronary stents [22, 23]
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