Economic analysis including long-term risks and costs of alternative diagnostic strategies to evaluate patients with chest pain

Background: Diagnosis costs for cardiovascular disease waste a large amount of healthcare resources. The aim of the study is to evaluate the clinical and economic outcomes of alternative diagnostic strategies in low risk chest pain patients. Methods: We evaluated direct and indirect downstream costs of 6 strategies: coronary angiography ( CA) after positive troponin I or T ( cTn-I or cTnT) ( strategy 1); after positive exercise electrocardiography ( ex-ECG) ( strategy 2); after positive exercise echocardiography ( ex-Echo) ( strategy 3); after positive pharmacologic stress echocardiography ( PhSE) ( strategy 4); after positive myocardial exercise stress single-photon emission computed tomography with technetium Tc 99m sestamibi ( ex- SPECT- Tc) ( strategy 5) and direct CA ( strategy 6). Results: The predictive accuracy in correctly identifying the patients was 83,1% for cTn- I, 87% for cTn- T, 85,1% for ex- ECG, 93,4% for ex- Echo, 98,5% for PhSE, 89,4% for ex- SPECT- Tc and 18,7% for CA. The cost per patient correctly identified results $ 2.051 for cTn- I, $ 2.086 for cTn- T, $ 1.890 for ex- ECG, $ 803 for ex- Echo, $ 533 for PhSE, $ 1.521 for ex- SPECT- Tc ($ 1.634 including cost of extra risk of cancer) and $ 29.673 for CA ($ 29.999 including cost of extra risk of cancer). The average relative cost- effectiveness of cardiac imaging compared with the PhSE equal to 1 ( as a cost comparator), the relative cost of ex- Echo is 1.5 x, of a ex- SPECT- Tc is 3.1 x, of a ex- ECG is 3.5 x, of cTnI is x 3.8, of cTnT is x 3.9 and of a CA is 56.3 x. Conclusion: Stress echocardiography based strategies are cost- effective versus alternative imaging strategies and the risk and cost of radiation exposure is void.