Cost-effectiveness of a conservative, ischemia-guided management strategy after non-Q-wave myocardial infarction: results of a randomized trial.
BACKGROUND
Use of coronary angiography after myocardial infarction has been controversial, with some physicians advocating routine use and others advocating selective use only after documentation of residual myocardial ischemia. The effects of these strategies on economic outcomes have not been established.


RESULTS
We analyzed data from a randomized, controlled clinical trial conducted in 17 Department of Veterans Affairs hospitals that enrolled 876 clinically uncomplicated patients 24 to 72 hours after an acute non-Q-wave myocardial infarction. The routine invasive strategy included early coronary angiography with revascularization based on established guidelines. The conservative, ischemia-guided strategy included noninvasive testing with radionuclide ventriculography and exercise thallium scintigraphy, followed by coronary angiography in patients with objective evidence of myocardial ischemia. We measured the cost of hospitalization and outpatient visits and tests during follow-up and calculated the incremental cost-effectiveness ratio. The conservative, ischemia-guided strategy had lower costs than the routine invasive strategy, both during the initial hospitalization ($14 733 versus $19 256, P<0.001) and after a mean follow-up of 1.9 years ($39 707 versus $41 893, P=0.04). The hazard ratio for death was 0.72 (confidence limits, 0.51 to 1.01) in the conservative strategy. The conservative strategy had lower costs and better outcomes in 76% of 1000 bootstrap replications, and a cost-effectiveness ratio below $50 000 per year of life added in 96% of replications.


CONCLUSIONS
A conservative, ischemia-guided strategy of selective coronary angiography and revascularization for patients who develop objective evidence of recurrent ischemia is more cost-effective than a strategy of routine coronary angiography after uncomplicated non-Q-wave myocardial infarction.
Barnett
Paul G
PG
VA Palo Alto Health Care System, Palo Alto, Calif, USA.
Chen
Shuo
S
Boden
William E
WE
Chow
Bruce
B
Every
Nathan R
NR
Lavori
Philip W
PW
Hlatky
Mark A
MA
D017023:Coronary Angiography; D003362:Cost-Benefit Analysis / Q000706:statistics & numerical data; D019468:Disease Management; D004562:Electrocardiography; D005260:Female; D017721:Hospital Costs / Q000706:statistics & numerical data*; D006787:Hospitals, Veterans / Q000191:economics* / Q000706:statistics & numerical data; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000150:complications / Q000175:diagnosis / Q000191:economics* / Q000628:therapy*; D017202:Myocardial Ischemia / Q000150:complications / Q000175:diagnosis / Q000191:economics* / Q000628:therapy*; D009204:Myocardial Revascularization / Q000191:economics; D016017:Odds Ratio; D011446:Prospective Studies; D019057:Quality-Adjusted Life Years; D015635:Radionuclide Ventriculography; D013794:Thallium Radioisotopes; D016896:Treatment Outcome; D014481:United States; D014493:United States Department of Veterans Affairs
D013794:Thallium Radioisotopes