The economic consequences of available diagnostic and prognostic strategies for the evaluation of stable angina patients: an observational assessment of the value of precatheterization ischemia
Leslee J. Shaw, PhD*  ,
Rory Hachamovitch, MD ,
Daniel S. Berman, MD ,
Thomas H. Marwick, MD ,
Michael S. Lauer, MD ,
Gary V. Heller, MD|| ,
Ami E. Iskandrian, MD ,
Karen L. Kesler, MS¶ ,
Mark I. Travin, MD# ,
Howard C. Lewin, MD ,
Robert C. Hendel, MD** ,
Salvador Borges-Neto, MD¶ ,
D. Douglas Miller, MD for the Economics of Noninvasive Diagnosis (END) Multicenter Study Group
* Division of Cardiology, Emory University, Atlanta, Georgia, USA
New York Presbyterian Hospital, Weill Medical College of Cornell University, New York, New York, USA
Cedars-Sinai Medical Center, Los Angeles, California; USA
Cleveland Clinic Foundation, Cleveland, Ohio, USA
|| Hartford Hospital, Hartford, Connecticut, USA
¶ Duke University Medical Center, Durham, North Carolina, USA
# Roger Williams Hospital, Providence, Rhode Island, USA
** Northwestern University, Chicago, Illinois, USA
Saint Louis University, Saint Louis, Missouri, USA
Allegheny University of the Health Sciences, Philadelphia, Pennsylvania, USA
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Figure 1 Rates of cardiac death or myocardial infarction (MI) and coronary revascularization (Revasc) by pretest clinical risk subsets of low, intermediate (Int) and high risk patients. The rates of  1 reversible perfusion defect and cardiac catheterization rates for patients undergoing a noninvasive diagnostic strategy are presented for low, Int, and high risk patients.
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Figure 2 The extent of coronary artery disease for matched cohorts of coronary disease pretest risk subsets. The rate of no coronary disease (No CAD) is lower for patients undergoing direct cardiac catheterization. The rate of single vessel coronary disease (SVD) is comparable between the two diagnostic strategies. The rate of multivessel coronary disease (MVD) is higher in patients with evidence of ischemia on their initial stress perfusion scan and in those with a high pretest risk of coronary disease.
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Figure 3 The percentage of low and high cost patients for patients with no reversible defect and reversible defects for the 5,826 stable chest pain patients undergoing stress perfusion imaging. On average, patients with a reversible perfusion defect were higher cost than those without a perfusion defect.
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Figure 4 The percentage of low and high cost patients for patients undergoing direct catheterization and initial stress perfusion imaging. On average, patients proceeding directly to cardiac catheterization were higher cost than those having an initial stress perfusion scan.
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Figure 5 Overall diagnostic and follow-up costs of care for direct catheterization and initial stress perfusion imaging are presented. Diagnostic and follow-up costs of care were 30% to 41% higher for patients undergoing direct cardiac catheterization. Solid bars = diagnostic cost; open bars = follow-up cost.
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Figure 6 Risk-adjusted predicted three-year costs as compared with observed three-year costs of care for patients undergoing nuclear imaging by the extent of myocardial ischemia. After controlling for pretest clinical risk and cardiac outcomes, significant (p < 0.0001) cost savings could be realized by decreasing resource use in patients with none to minimal ischemia on their nuclear scan.
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