Kuntz K M, Fleischmann K E, Hunink M G, Douglas P S
Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts, USA.
Ann Intern Med. 1999 May 4;130(9):709-18. doi: 10.7326/0003-4819-130-9-199905040-00002.
Many noninvasive tests exist to determine whether patients should undergo coronary angiography. The routine use of coronary angiography without previous noninvasive testing is typically not advocated.
To determine the cost-effectiveness of diagnostic strategies for patients with chest pain.
Cost-effectiveness analysis.
Published data.
Patients who present with chest pain, have no history of myocardial infarction, and are able to perform an exercise stress test.
Lifetime.
Societal.
No testing, exercise electrocardiography, exercise echocardiography, exercise single-photon emission computed tomography (SPECT), and coronary angiography alone.
Quality-adjusted life expectancy, lifetime cost, and incremental cost-effectiveness.
RESULTS OF BASE-CASE ANALYSIS: The incremental cost-effectiveness ratio of routine coronary angiography compared with exercise echocardiography was $36,400 per quality-adjusted life-year (QALY) saved for 55-year-old men with typical angina. For 55-year-old men with atypical angina, exercise echocardiography compared with exercise electrocardiography cost $41,900 per QALY saved. If adequate exercise echocardiography was not available, exercise SPECT cost $54,800 per QALY saved compared with exercise electrocardiography for these patients. For 55-year-old men with nonspecific chest pain, the incremental cost-effectiveness ratio of exercise electrocardiography compared with no testing was $57,700 per QALY saved.
On the basis of a probabilistic sensitivity analysis, there is a 75% chance that exercise echocardiography costs less than $50,900 per QALY saved for 55-year-old men with atypical angina.
Exercise electrocardiography or exercise echocardiography resulted in reasonable cost-effectiveness ratios for patients at mild to moderate risk for coronary artery disease in terms of age, sex, and type of chest pain. Coronary angiography without previous noninvasive testing resulted in reasonable cost-effectiveness ratios for patients with a high pretest probability of coronary artery disease.
存在多种非侵入性检查来确定患者是否应接受冠状动脉造影。通常不提倡在未进行先前非侵入性检查的情况下常规使用冠状动脉造影。
确定胸痛患者诊断策略的成本效益。
成本效益分析。
已发表的数据。
出现胸痛、无心肌梗死病史且能够进行运动负荷试验的患者。
终身。
社会。
不进行检查、运动心电图、运动超声心动图、运动单光子发射计算机断层扫描（SPECT）以及单独进行冠状动脉造影。
质量调整生命预期、终身成本和增量成本效益。
对于患有典型心绞痛的55岁男性，与运动超声心动图相比，常规冠状动脉造影的增量成本效益比为每挽救一个质量调整生命年（QALY）36,400美元。对于患有非典型心绞痛的55岁男性，与运动心电图相比，运动超声心动图每挽救一个QALY的成本为41,900美元。如果无法进行充分的运动超声心动图检查，对于这些患者，与运动心电图相比，运动SPECT每挽救一个QALY的成本为54,800美元。对于患有非特异性胸痛的55岁男性，与不进行检查相比，运动心电图的增量成本效益比为每挽救一个QALY 57,700美元。
基于概率敏感性分析，对于患有非典型心绞痛的55岁男性，运动超声心动图每挽救一个QALY的成本低于50,900美元的概率为75%。
就年龄、性别和胸痛类型而言，运动心电图或运动超声心动图对于冠状动脉疾病风险为轻度至中度的患者产生了合理的成本效益比。在未进行先前非侵入性检查的情况下进行冠状动脉造影对于冠状动脉疾病预测试概率高的患者产生了合理的成本效益比。
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