title: The optimal imaging strategy for patients with stable chest pain: a cost-effectiveness analysis.
abstract: BACKGROUND
  The optimal imaging strategy for patients with stable chest pain is uncertain.
  
  
  OBJECTIVE
  To determine the cost-effectiveness of different imaging strategies for patients with stable chest pain.
  
  
  METHODS
  Microsimulation state-transition model.
  
  
  METHODS
  Published literature.
  
  
  METHODS
  60-year-old patients with a low to intermediate probability of coronary artery disease (CAD).
  
  
  METHODS
  Lifetime.
  
  
  CONCLUSIONS
  The United States, the United Kingdom, and the Netherlands.
  
  
  METHODS
  Coronary computed tomography (CT) angiography, cardiac stress magnetic resonance imaging, stress single-photon emission CT, and stress echocardiography.
  
  
  METHODS
  Lifetime costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios.
  
  
  RESULTS
  The strategy that maximized QALYs and was cost-effective in the United States and the Netherlands began with coronary CT angiography, continued with cardiac stress imaging if angiography found at least 50% stenosis in at least 1 coronary artery, and ended with catheter-based coronary angiography if stress imaging induced ischemia of any severity. For U.K. men, the preferred strategy was optimal medical therapy without catheter-based coronary angiography if coronary CT angiography found only moderate CAD or stress imaging induced only mild ischemia. In these strategies, stress echocardiography was consistently more effective and less expensive than other stress imaging tests. For U.K. women, the optimal strategy was stress echocardiography followed by catheter-based coronary angiography if echocardiography induced mild or moderate ischemia.
  
  
  RESULTS
  Results were sensitive to changes in the probability of CAD and assumptions about false-positive results.
  
  
  CONCLUSIONS
  All cardiac stress imaging tests were assumed to be available. Exercise electrocardiography was included only in a sensitivity analysis. Differences in QALYs among strategies were small.
  
  
  CONCLUSIONS
  Coronary CT angiography is a cost-effective triage test for 60-year-old patients who have nonacute chest pain and a low to intermediate probability of CAD.
  
  
  BACKGROUND
  Erasmus University Medical Center.
authors.forename: Tessa S S
authors.initials: TS
authors.lastname: Genders
authors.forename: Steffen E
authors.initials: SE
authors.lastname: Petersen
authors.forename: Francesca
authors.initials: F
authors.lastname: Pugliese
authors.forename: Amardeep G
authors.initials: AG
authors.lastname: Dastidar
authors.forename: Kirsten E
authors.initials: KE
authors.lastname: Fleischmann
authors.forename: Koen
authors.initials: K
authors.lastname: Nieman
authors.forename: M G Myriam
authors.initials: MG
authors.lastname: Hunink
mesh_terms: D002637:Chest Pain / Q000209:etiology*; D003198:Computer Simulation; D017023:Coronary Angiography / Q000191:economics; D003324:Coronary Artery Disease / Q000175:diagnosis*; D003362:Cost-Benefit Analysis; D003952:Diagnostic Imaging / Q000191:economics*; D004452:Echocardiography / Q000191:economics; D004562:Electrocardiography; D005080:Exercise Test; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging / Q000191:economics; D008297:Male; D008875:Middle Aged; D011788:Quality of Life; D012680:Sensitivity and Specificity; D015899:Tomography, Emission-Computed, Single-Photon / Q000191:economics; D014057:Tomography, X-Ray Computed / Q000191:economics