Biomedical Engineering and Imaging Sciences, King's College London, London, UK
Centre for Medical Engineering, KiTEC - King's Technology Evaluation Centre, King's College London, London, UK.
Open Heart. 2022 Apr;9(1). doi: 10.1136/openhrt-2021-001700.
Given recent data on published diagnostic accuracies, this study sought to determine the most cost-effective diagnostic strategy for detection of significant coronary artery disease (CAD) in stable angina patients using invasive coronary angiography (ICA) and fractional flow reserve (FFR) as the reference standard.
A probabilistic decision-analytical model was developed which modelled a cohort of patients with stable angina. We investigated 17 diagnostic strategies between standalone and combination of different imaging tests to establish a correct diagnosis of CAD, using no testing as the baseline reference. These tests included CT coronary angiography (CTCA), stress echocardiography, CT-based FFR, single-photon emission computed tomography (SPECT), cardiovascular magnetic resonance (CMR), positron emission tomography, ICA, and ICA with FFR. Incremental cost-effectiveness ratios were calculated as the additional cost per correct diagnosis.
SPECT followed by CTCA and ICA-FFR is the most cost-effective strategy between a cost-effectiveness threshold (CET) value of £1000-£3000 per correct diagnosis. CMR followed by CTCA and ICA-FFR is cost-effective within a CET range of £3000-£17 000 per correct diagnosis. CMR and ICA-FFR is cost-effective within a CET range of £17 000-£24 000. ICA-FFR as first line is the most-cost effective if the CET value exceeds the £24 000 per correct diagnosis. Sensitivity analysis showed that direct ICA-FFR may be cost-effective in patients with a high pre-test probability of CAD.
First-line testing with functional imaging is cost-effective at low to intermediate value of correct diagnosis in patients with low to intermediate risk of CAD. ICA is not cost effective although ICA-FFR may be at higher CET.
鉴于近期发表的诊断准确性数据，本研究旨在确定使用有创冠状动脉造影（ICA）和血流储备分数（FFR）作为参考标准检测稳定型心绞痛患者中显著冠状动脉疾病（CAD）的最具成本效益的诊断策略。
开发了一种概率决策分析模型，该模型对稳定型心绞痛患者队列进行建模。我们研究了 17 种不同影像学检查的诊断策略，以建立 CAD 的正确诊断，不进行任何检查作为基线参考。这些检查包括 CT 冠状动脉造影（CTCA）、负荷超声心动图、基于 CT 的 FFR、单光子发射计算机断层扫描（SPECT）、心血管磁共振（CMR）、正电子发射断层扫描、ICA 和 ICA 与 FFR。增量成本效益比计算为每正确诊断的额外成本。
SPECT 后接 CTCA 和 ICA-FFR 是在成本效益阈值（CET）值为每正确诊断 1000-3000 英镑之间最具成本效益的策略。CMR 后接 CTCA 和 ICA-FFR 在 CET 范围为每正确诊断 3000-17000 英镑之间具有成本效益。CMR 和 ICA-FFR 在 CET 范围为 17000-24000 英镑之间具有成本效益。如果 CET 值超过每正确诊断 24000 英镑，则 ICA-FFR 作为一线治疗是最具成本效益的。敏感性分析表明，在 CAD 高术前概率的患者中，直接 ICA-FFR 可能具有成本效益。
在 CAD 低至中度风险的患者中，在低至中等正确诊断价值时，一线功能性影像学检查具有成本效益。尽管 ICA-FFR 可能具有更高的 CET，但 ICA 并不具有成本效益。
