title: Using stress testing to guide primary prevention of coronary heart disease among intermediate-risk patients: a cost-effectiveness analysis.
abstract: BACKGROUND
  Noninvasive stress testing might guide the use of aspirin and statins for primary prevention of coronary heart disease, but it is unclear if such a strategy would be cost effective.
  
  
  RESULTS
  We compared the status quo, in which the current national use of aspirin and statins was simulated, with 3 other strategies: (1) full implementation of Adult Treatment Panel III guidelines, (2) a treat-all strategy in which all intermediate-risk persons received statins (men and women) and aspirin (men only), and (3) a test-and-treat strategy in which all persons with an intermediate risk of coronary heart disease underwent stress testing and those with a positive test were treated with high-intensity statins (men and women) and aspirin (men only). Healthcare costs, coronary heart disease events, and quality-adjusted life years from 2011 to 2040 were projected. Under a variety of assumptions, the treat-all strategy was the most effective and least expensive strategy. Stress electrocardiography was more effective and less expensive than other test-and-treat strategies, but it was less expensive than treat all only if statin cost exceeded $3.16/pill or if testing increased adherence from <22% to >75%. However, stress electrocardiography could be cost effective in persons initially nonadherent to the treat-all strategy if it raised their adherence to 5% and cost saving if it raised their adherence to 13%.
  
  
  CONCLUSIONS
  When generic high-potency statins are available, noninvasive cardiac stress testing to target preventive medications is not cost effective unless it substantially improves adherence.
authors.affiliation: Brigham and Women's Hospital, Cardiovascular Division, 75 Francis St, Boston, MA 02115, USA. bgalper@partners.org
authors.forename: Benjamin Z
authors.initials: BZ
authors.lastname: Galper
authors.forename: Andrew
authors.initials: A
authors.lastname: Moran
authors.forename: Pamela G
authors.initials: PG
authors.lastname: Coxson
authors.forename: Mark J
authors.initials: MJ
authors.lastname: Pletcher
authors.forename: Paul
authors.initials: P
authors.lastname: Heidenreich
authors.forename: Lawrence D
authors.initials: LD
authors.lastname: Lazar
authors.forename: Nicolas
authors.initials: N
authors.lastname: Rodondi
authors.forename: Y Claire
authors.initials: YC
authors.lastname: Wang
authors.forename: Lee
authors.initials: L
authors.lastname: Goldman
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001241:Aspirin / Q000191:economics / Q000627:therapeutic use; D003198:Computer Simulation; D003327:Coronary Disease / Q000175:diagnosis / Q000191:economics* / Q000517:prevention & control*; D003362:Cost-Benefit Analysis; D004562:Electrocardiography / Q000379:methods; D005080:Exercise Test; D005260:Female; D017048:Health Care Costs; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000191:economics / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D010349:Patient Compliance; D019057:Quality-Adjusted Life Years; D018570:Risk Assessment
chemical_list: D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D001241:Aspirin