Emergency department triage strategies for acute chest pain using creatine kinase-MB and troponin I assays: a cost-effectiveness analysis.
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.


METHODS
Cost-effectiveness analysis.


METHODS
Prospective data from 1066 patients with chest pain and from the published literature.


METHODS
Patients admitted with acute chest pain.


METHODS
Lifetime.


CONCLUSIONS
Societal.


METHODS
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.


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


RESULTS
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
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.
Polanczyk
C A
CA
Brigham and Women's Hospital, Harvard Medical School, and Harvard School of Public Health, Boston, Massachusetts, USA.
Kuntz
K M
KM
Sacks
D B
DB
Johnson
P A
PA
Lee
T H
TH
D015415:Biomarkers / Q000032:analysis; D002637:Chest Pain / Q000209:etiology*; D003362:Cost-Benefit Analysis; D003402:Creatine Kinase / Q000032:analysis*; D003661:Decision Support Techniques; D004562:Electrocardiography; D004636:Emergency Service, Hospital / Q000191:economics*; D005080:Exercise Test; D006760:Hospitalization; D006801:Humans; D007527:Isoenzymes; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000175:diagnosis*; D012680:Sensitivity and Specificity; D014218:Triage / Q000191:economics*; D019210:Troponin I / Q000032:analysis*
D015415:Biomarkers; D007527:Isoenzymes; D019210:Troponin I; D003402:Creatine Kinase