Department of Cardiology, Northwick park Hospital, Harrow, United Kingdom; Department of Cardiology, Royal Brompton Hospital, United Kingdom; Biomedical Research Unit, National Heart and Lung Institute, Imperial College, London, United Kingdom.
Department of Cardiology, Northwick park Hospital, Harrow, United Kingdom.
Int J Cardiol. 2018 May 15;259:1-7. doi: 10.1016/j.ijcard.2018.01.112.
Exercise ECG (Ex-ECG) is advocated by guidelines for patients with low - intermediate probability of coronary artery disease (CAD). However, there are no randomized studies comparing Ex-ECG with exercise stress echocardiography (ESE) evaluating long term cost-effectiveness of each management strategy.
Accordingly, 385 patients with no prior CAD and low-intermediate probability of CAD (mean pre-test probability 34%), were randomized to undergo either Ex-ECG (194 patients) or ESE (191 patients). The primary endpoint was clinical effectiveness defined as the positive predictive value (PPV) for the detection of CAD of each test. Cost-effectiveness was derived using the cumulative costs incurred by each diagnostic strategy during a mean of follow up of 3.0 years.
The PPV of ESE and Ex-ECG were 100% and 64% (p = 0.04) respectively for the detection of CAD. There were fewer clinic (31 vs 59, p < 0.01) and emergency visits (14 vs 30, p = 0.01) and lower number of hospital bed days (8 vs 29, p < 0.01) in the ESE arm, with fewer patients undergoing coronary angiography (13.4% vs 6.3%, p = 0.02). The overall cumulative mean costs per patient were £796 for Ex-ECG and £631 for ESE respectively (p = 0.04) equating to a >20% reduction in cost with an ESE strategy with no difference in the combined end-point of death, myocardial infarction, unplanned revascularization and hospitalization for chest pain between ESE and Ex-ECG (3.2% vs 3.7%, p = 0.38).
In patients with low to intermediate pretest probability of CAD and suspected angina, an ESE management strategy is cost-effective when compared with Ex-ECG during long term follow up.
运动心电图（Ex-ECG）被指南推荐用于低-中度冠状动脉疾病（CAD）可能性的患者。然而，目前尚无比较 Ex-ECG 与运动应激超声心动图（ESE）的随机研究，评估每种管理策略的长期成本效益。
因此，将 385 名无既往 CAD 和低-中度 CAD 可能性的患者（平均术前概率为 34%）随机分为 Ex-ECG 组（194 例）或 ESE 组（191 例）。主要终点是临床有效性，定义为每种检测方法对 CAD 检测的阳性预测值（PPV）。使用平均 3.0 年随访期间每种诊断策略的累积成本来推导成本效益。
ESE 和 Ex-ECG 对 CAD 的检出率分别为 100%和 64%（p=0.04）。ESE 组的就诊（31 例 vs 59 例，p<0.01）和急诊就诊（14 例 vs 30 例，p=0.01）以及住院天数（8 例 vs 29 例，p<0.01）较少，接受冠状动脉造影的患者较少（13.4% vs 6.3%，p=0.02）。每位患者的总体累积平均成本分别为 Ex-ECG 组的 796 英镑和 ESE 组的 631 英镑（p=0.04），ESE 策略的成本降低了>20%，但 ESE 与 Ex-ECG 之间的死亡率、心肌梗死、计划外血运重建和因胸痛住院的联合终点无差异（3.2% vs 3.7%，p=0.38）。
在低至中度 CAD 术前概率和疑似心绞痛的患者中，与 Ex-ECG 相比，ESE 管理策略在长期随访期间具有成本效益。
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