1 The University of Texas Health Sciences Center at Houston, Houston, TX.
AJR Am J Roentgenol. 2013 Oct;201(4):710-9. doi: 10.2214/AJR.12.9946.
We evaluated three diagnostic strategies with the objective of comparing the current standard of care for individuals presenting acute chest pain and no history of coronary artery disease (CAD) with a novel diagnostic strategy using an emerging technology (blood-pool contrast agent [BPCA]) to identify the potential benefits and cost reductions.
A decision analytic model of diagnostic strategies and outcomes using a BPCA and a conventional agent for CT angiography (CTA) in patients with acute chest pain was built. The model was used to evaluate three diagnostic strategies: CTA using a BPCA followed by invasive coronary angiography (ICA), CTA using a conventional agent followed by ICA, and ICA alone.
The use of the two CTA-based triage tests before ICA in a population with a CAD prevalence of less than 47% was predicted to be more cost-effective than ICA alone. Using the base-case values and a cost premium for BPCA over the conventional CT agent (cost of BPCA ≈ 5× that of a conventional agent) showed that CTA with a BPCA before ICA resulted in the most cost-effective strategy; the other strategies were ruled out by simple dominance. The model strongly depends on the rates of complications from the diagnostic tests included in the model. In a population with an elevated risk of contrast-induced nephropathy (CIN), a significant premium cost per BPCA dose still resulted in the alternative whereby CTA using BPCA was more cost-effective than CTA using a conventional agent. A similar effect was observed for potential complications resulting from the BPCA injection. Conversely, in the presence of a similar complication rate from BPCA, the diagnostic strategy of CTA using a conventional agent would be the optimal alternative.
BPCAs could have a significant impact in the diagnosis of acute chest pain, in particular for populations with high incidences of CIN. In addition, a BPCA strategy could garner further savings if currently excluded phenomena including renal disease and incidental findings were included in the decision model.
我们评估了三种诊断策略，旨在比较目前针对无冠心病（CAD）病史的急性胸痛患者的标准护理与使用新兴技术（血池对比剂[BPCA]）的新型诊断策略，以确定潜在的益处和成本降低。
建立了一种使用 BPCA 和 CT 血管造影（CTA）的常规造影剂在急性胸痛患者中的诊断策略和结果的决策分析模型。该模型用于评估三种诊断策略：使用 BPCA 进行 CTA 后进行有创冠状动脉造影（ICA）、使用常规造影剂进行 CTA 后进行 ICA 以及单独进行 ICA。
在 CAD 患病率低于 47%的人群中，在 ICA 之前使用两种基于 CTA 的分诊试验比单独使用 ICA 更具成本效益。使用基础病例值和 BPCA 相对于常规 CT 造影剂的成本溢价（BPCA 的成本约为常规造影剂的 5 倍）表明，在 ICA 之前使用 BPCA 进行 CTA 可带来最具成本效益的策略；其他策略被简单地排除了。该模型强烈依赖于模型中包含的诊断测试的并发症发生率。在患有造影剂肾病（CIN）风险较高的人群中，每 BPCA 剂量的显着溢价成本仍然使 BPCA 进行 CTA 比使用常规造影剂进行 CTA 更具成本效益。对 BPCA 注射可能导致的潜在并发症也观察到类似的影响。相反，如果 BPCA 导致并发症的发生率相似，则使用常规造影剂进行 CTA 的诊断策略将是最佳选择。
BPCA 可能会对急性胸痛的诊断产生重大影响，特别是对于 CIN 发生率较高的人群。此外，如果将目前排除在决策模型之外的现象（包括肾脏疾病和偶然发现）纳入该模型，BPCA 策略可能会带来进一步的节省。
