European Heart Journal Advance Access originally published online on April 13, 2006
European Heart Journal 2006 27(11):1382-1383; doi:10.1093/eurheartj/ehi860
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What is the most useful and cost-effective strategy to screen for left ventricular systolic dysfunction in clinical practice?
Ohsaki Heart Clinic
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Okada Medical Clinic
Nagano
Japan
Okada Medical Clinic
Nagano
Japan
With interest we read the article ‘What is the most cost-effective strategy to screen for left ventricular (LV) systolic dysfunction: natriuretic peptides, the electrocardiogram, hand-held echocardiography, traditional echocardiography, or their combination?’ by Galasko et al.1 However, we do not agree with the conclusion that the electrocardiogram (ECG), the N-terminal pro-brain natriuretic peptide (NTproBNP), and hand-held echocardiography (HE) can be used cost-effectively for screening and that the most cost-effective approach involves pre-screening with NTproBNP or ECG prior to HE prior to formal traditional echocardiography (TE).
Both the ECG and the NTproBNP are important and fundamental tests used for the diagnosis of heart failure. However, as their characteristics differ from the echocardiogram, they cannot necessarily be used as substitutes for the echocardiogram. As for screening tests, high sensitivity is required at the expense of specificity. In the high-risk group in this study, the sensitivity of ECG declined to 90% and that of NTproBNP to 76%. Given the high prevalence, the sample size is large and the sensitivity of the high-risk group would reflect the real value. Moreover, when a two-step screening strategy (ECG or NTproBNP combined with HE) is used, the sensitivity further decreases. Although a cost saving is achieved, the number of false-negative results increases, which cannot be disregarded in the high-risk group because of the negative consequences associated with a missed diagnosis.
In contrast, the sensitivity of HE remained at 97% even in the high-risk group. This implies that even HE is a useful screening test for LV systolic dysfunction, as more true-positive patients would be identified than with the two-step screening strategy.
Finally, the authors' sensitivity analysis used an increased cost for HE, from 37.5 
to 50 . If, on the other hand, the cost for HE decreased a little from 37.5 to 30 , then the cost-effectiveness of HE alone prior to TE would be more cost-effective than ECG prior to HE prior to TE. Thus, HE alone strategy would be the most useful and cost-effective and identify more true-positive patients in clinical practice than the two-step screening strategy proposed.
References
- Galasko GI, Barnes SC, Collinson P, Lahiri A, Senior R. (2006) What is the most cost-effective strategy to screen for left ventricular systolic dysfunction: natriuretic peptides, the electrocardiogram, hand-held echocardiography, traditional echocardiography, or their combination? Eur Heart J 27:193–200.
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