title: Cost-effectiveness of initial stress cardiovascular MR, stress SPECT or stress echocardiography as a gate-keeper test, compared with upfront invasive coronary angiography in the investigation and management of patients with stable chest pain: mid-term outcomes from the CECaT randomised controlled trial.
abstract: OBJECTIVE
  To compare outcomes and cost-effectiveness of various initial imaging strategies in the management of stable chest pain in a long-term prospective randomised trial.
  
  
  METHODS
  Regional cardiothoracic referral centre in the east of England.
  
  
  METHODS
  898 patients (69% man) entered the study with 869 alive at 2 years of follow-up. Patients were included if they presented for assessment of stable chest pain with a positive exercise test and no prior history of ischaemic heart disease. Exclusion criteria were recent infarction, unstable symptoms or any contraindication to stress MRI.
  
  
  METHODS
  The primary outcomes of this follow-up study were survival up to a minimum of 2 years post-treatment, quality-adjusted survival and cost-utility of each strategy.
  
  
  RESULTS
  898 patients were randomised. Compared with angiography, mortality was marginally higher in the groups randomised to cardiac MR (HR 2.6, 95% CI 1.1 to 6.2), but similar in the single photon emission CT-methoxyisobutylisonitrile (SPECT-MIBI; HR 1.0, 95% CI 0.4 to 2.9) and ECHO groups (HR 1.6, 95% CI 0.6 to 4.0). Although SPECT-MIBI was marginally superior to other non-invasive tests there were no other significant differences between the groups in mortality, quality-adjusted survival or costs.
  
  
  CONCLUSIONS
  Non-invasive cardiac imaging can be used safely as the initial diagnostic test to diagnose coronary artery disease without adverse effects on patient outcomes or increased costs, relative to angiography. These results should be interpreted in the context of recent advances in imaging technology.
  
  
  BACKGROUND
  ISRCTN 47108462, UKCRN 3696.
authors: MRC Biostatistics Unit, Institute of Public Health, Cambridge, UK.
authors: Howard
authors: H
authors: Thom
authors: Nicholas E J
authors: NE
authors: West
authors: Vikki
authors: V
authors: Hughes
authors: Matthew
authors: M
authors: Dyer
authors: Martin
authors: M
authors: Buxton
authors: Linda D
authors: LD
authors: Sharples
authors: Christopher H
authors: CH
authors: Jackson
authors: Andrew M
authors: AM
authors: Crean
mesh_terms: D002637:Chest Pain / Q000175:diagnosis* / Q000401:mortality; D017023:Coronary Angiography / Q000191:economics*; D003324:Coronary Artery Disease / Q000175:diagnosis* / Q000401:mortality; D003362:Cost-Benefit Analysis; D025401:Echocardiography, Stress / Q000191:economics*; D004739:England / Q000453:epidemiology; D005080:Exercise Test; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging / Q000191:economics*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D015996:Survival Rate; D015899:Tomography, Emission-Computed, Single-Photon / Q000191:economics*