European Heart Journal Advance Access originally published online on September 26, 2006
European Heart Journal 2006 27(20):2448-2458; doi:10.1093/eurheartj/ehl204
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Incremental cost-effectiveness of exercise echocardiography vs. SPECT imaging for the evaluation of stable chest pain
1 Cedars-Sinai Medical Center, David Geffen UCLA School of Medicine, Taper Building, Room 125, 8700 Beverly Boulevard, Los Angeles, CA 90048, USA
2 University of Queensland School of Medicine, Brisbane, Australia
3 Indiana University School of Medicine, Indianapolis, IN, USA
4 Hartford Hospital, Hartford, Connecticut, USA
5 Asheville Cardiology Associates, Asheville, NC, USA
6 St Louis University School of Medicine, St. Louis, MO, USA
Received 31 August 2005; revised 6 July 2006; accepted 10 August 2006; online publish-ahead-of-print 26 September 2006.
* Corresponding author. Tel: +1 404 229 7339; fax: +1 404 875 6086. E-mail address: leslee.shaw{at}cshs.org
See page 2378 for the editorial comment on this article (doi:10.1093/eurheartj/ehl225)
Aims Technological advances in cardiac imaging have led to dramatic increases in test utilization and consumption of a growing proportion of cardiovascular healthcare costs. The opportunity costs of strategies favouring exercise echocardiography or SPECT imaging have been incompletely evaluated.
Methods and results We examined prognosis and cost-effectiveness of exercise echocardiography (n=4884) vs. SPECT (n=4637) imaging in stable, intermediate risk, chest pain patients. Ischaemia extent was defined as the number of vascular territories with echocardiographic wall motion or SPECT perfusion abnormalities. Cox proportional hazard models were employed to assess time to cardiac death or myocardial infarction (MI). Total cardiovascular costs were summed (discounted and inflation-corrected) throughout follow-up. A cost-effectiveness ratio <$50 000 per life year saved (LYS) was considered favourable for economic efficiency. The risk-adjusted 3-year death or MI rates classified by extent of ischaemia were similar, ranging from 2.3 to 8.0% for echocardiography and from 3.5 to 11.0% for SPECT (model 
2=216; P<0.0001; interaction P=0.24). Cost-effectiveness ratios for echocardiography were <$20 000/LYS when the annual risk of death or MI was <2%. However, when yearly cardiac event rate were >2%, cost-effectiveness ratios for echocardiography vs. SPECT were in the range of $66 686–$419 522/LYS. For patients with established coronary disease (i.e. 
2% annual event risk), SPECT ischaemia was associated with earlier and greater utilization of coronary revascularization (P<0.0001) resulting in an incremental cost-effectiveness ratio of $32 381/LYS.
Conclusion Health care policies aimed at allocating limited resources can be effectively guided by applying clinical and economic outcomes evidence. A strategy aimed at cost-effective testing would support using echocardiography in low-risk patients with suspected coronary disease, whereas those higher risk patients benefit from referral to SPECT imaging.
Key Words: Cost effectiveness • Prognosis • Echocardiography • SPECT • Stable angina
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EHJ 2006 27: 2378-2379.[Extract] [Full Text]
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  D. Poldermans and J. J. Bax Selecting optimal non-invasive cardiac imaging stress test in intermediate-risk patients using cost effectiveness analysis Eur. Heart J., October 2, 2006; 27(20): 2378 - 2379. [Full Text] [PDF]
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