Ann Intern Med. 2015 Apr 7;162(7):474-84. doi: 10.7326/M14-0027.
The optimal imaging strategy for patients with stable chest pain is uncertain.
To determine the cost-effectiveness of different imaging strategies for patients with stable chest pain.
Microsimulation state-transition model.
Published literature.
60-year-old patients with a low to intermediate probability of coronary artery disease (CAD).
Lifetime.
The United States, the United Kingdom, and the Netherlands.
Coronary computed tomography (CT) angiography, cardiac stress magnetic resonance imaging, stress single-photon emission CT, and stress echocardiography.
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 were sensitive to changes in the probability of CAD and assumptions about false-positive results.
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.
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.
Erasmus University Medical Center.
对于稳定型胸痛患者，最佳的影像学检查策略尚不确定。
旨在确定不同影像学检查策略对于稳定型胸痛患者的成本效益。
微观模拟状态转移模型。
已发表的文献。
年龄 60 岁、CAD 低至中度可能性的患者。
终生。
美国、英国和荷兰。
冠状动脉 CT 血管造影、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。
终生成本、质量调整生命年（QALY）和增量成本效益比。
在最大限度提高 QALY 并具有成本效益的情况下，美国和荷兰的起始策略为冠状动脉 CT 血管造影，如果血管造影发现至少 1 支冠状动脉狭窄≥50%，则继续进行心脏负荷影像学检查，如果负荷影像学检查诱导出任何严重程度的缺血，则进行基于导管的冠状动脉造影。对于英国男性，如果冠状动脉 CT 血管造影仅发现中度 CAD 或负荷影像学检查仅诱导轻度缺血，则首选不进行基于导管的冠状动脉造影的最佳药物治疗策略。在这些策略中，负荷超声心动图始终比其他负荷影像学检查更有效且更经济。对于英国女性，如果超声心动图诱导出轻度或中度缺血，则最佳策略为负荷超声心动图后行基于导管的冠状动脉造影。
结果对 CAD 概率和假阳性结果的假设变化敏感。
假设所有心脏负荷影像学检查均可用。仅在敏感性分析中纳入运动心电图。策略之间的 QALY 差异较小。
对于年龄 60 岁、非急性胸痛且 CAD 低至中度可能性的患者，冠状动脉 CT 血管造影是一种具有成本效益的筛查试验。
伊拉斯谟大学医学中心。
