The Optimal Imaging Strategy for Patients With Stable Chest Pain A Cost-Effectiveness Analysis
The Optimal Imaging Strategy for Patients With Stable Chest Pain A Cost-Effectiveness Analysis
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DOI：
10.7326/m14-0027
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发表时间：
2015-04-07
影响因子：
39.2
通讯作者：
Hunink, M. G. Myriam
中科院分区：
文献类型：
--
作者：
Genders, Tessa S. S.;Petersen, Steffen E.;Hunink, M. G. Myriam
背景资料：稳定性胸痛患者的最佳成像策略是不确定的。目的：确定稳定性胸痛患者不同成像策略的成本效益。设计：微观模拟状态转换模型。数据来源：已发表文献。目标人群：60岁的低至中等概率冠状动脉疾病（CAD）患者。时间范围：终身。视角：美国、英国和荷兰。干预：冠状动脉计算机断层扫描（CT）血管造影术、心脏负荷磁共振成像、负荷单光子发射CT和负荷超声心动图。结果测量：终身成本、质量调整生命年（QIRES）和增量成本效益比。基础病例分析结果：在美国和荷兰，最大限度地提高QALTS和成本效益的策略始于冠状动脉CT血管造影，如果血管造影发现至少1支冠状动脉至少50%狭窄，则继续进行心脏负荷成像，如果负荷成像诱导任何严重程度的缺血，则以基于导管的冠状动脉血管造影结束。对美国K.对于男性，如果冠状动脉CT血管造影仅发现中度CAD或应力成像仅引起轻度缺血，则首选策略是最佳药物治疗，而不进行基于导管的冠状动脉血管造影。在这些策略中，负荷超声心动图始终比其他负荷成像测试更有效，更便宜。对美国K.女性，最佳策略是负荷超声心动图，然后基于导管的冠状动脉造影术，如果超声心动图引起轻度或中度ischemia.Results的敏感性分析：结果是敏感的CAD的概率和假阳性结果的假设的变化。运动心电图仅纳入敏感性分析。策略之间的差异在QPWs是small.Conclusion：冠状动脉CT血管造影是一个具有成本效益的分流测试60岁的患者谁有非急性胸痛和CAD的低到中等的概率。
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.Design: Microsimulation state-transition model.Data Sources: Published literature.Target Population: 60-year-old patients with a low to intermediate probability of coronary artery disease (CAD).Time Horizon: Lifetime.Perspective: The United States, the United Kingdom, and the Netherlands.Intervention: Coronary computed tomography (CT) angiography, cardiac stress magnetic resonance imaging, stress single-photon emission CT, and stress echocardiography.Outcome Measures: Lifetime costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios.Results of Base-Case Analysis: 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 of Sensitivity Analysis: Results were sensitive to changes in the probability of CAD and assumptions about false-positive results.Limitations: 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.Conclusion: 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.