In This Video
- The primary choice for initial testing during the evaluation of low-risk stable chest pain is controversial and current AHA/ACC guidelines stem from 2012
- Researchers at Massachusetts General Hospital compared the effects of anatomic assessment of coronary artery disease with coronary CT angiography versus functional assessment of myocardial ischemia with stress testing
- The cost-effectiveness analysis looked at health care costs, quality of life and life expectancy over a lifetime
- The findings showed improved preventive statin treatment, fewer invasive testing and revascularization procedures, and lower costs with anatomic versus functional assessment, suggesting that coronary CTA may be more efficient as a first-line test
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Every year, more than 8.7 million patients undergo diagnostic testing for suspected coronary artery disease (CAD) with 95% of patients receiving a functional test. However, recent clinical trials have lead to considerable debate as to which approach should be used for the initial testing.
Led by Udo Hoffmann, MD, MPH, professor of radiology and director of the Cardiovascular Imaging Research Center (CIRC) at Massachusetts General Hospital, a team of scientists at Mass General and collaborators from the PROMISE trial recently sought to address this question. In a cost-effectiveness analysis reported in December 2020 in JAMA Network Open, they modeled the consequences of beginning the evaluation with the anatomic assessment of CAD by coronary CT angiography versus functional assessment of myocardial ischemia with stress testing.
SLIDE 1: I am going to summarize our cost-effectiveness analysis of noninvasive testing in low-risk chest pain published in JAMA Network Open.
SLIDE 2: Three decades ago, most patients with suspected stable coronary artery disease presented with typical chest pain, induced by exercise and relieved with nitroglycerin.
At the time, functional testing for myocardial ischemia had a high positivity rate and the belief was that revascularization of coronary stenoses would prolong lives.
SLIDE 3: Today, however, typical symptoms of obstructive coronary artery disease are uncommon, and its clinical presentation is rather atypical due to improved lifestyle and prevention with statin therapy.
With this, functional testing for myocardial ischemia has become less effective, with a low positivity rate.
Moreover, based on randomized trials, today we know that treating coronary artery disease with optimal medical therapy is as good as revascularization.
SLIDE 4: Since the early 2000s, anatomical testing of coronary artery disease with Coronary CT angiography allows the noninvasive visualization of coronary artery plaques.
The detection of the presence and extent of underlying coronary artery disease further allows the tailoring of preventive medical therapy—for example, with statins.
SLIDE 5: Yet, today, anatomical testing is the test of choice in less than 5% of patients with suspected obstructive CAD in the U.S.
SLIDE 6: Therefore, we conducted a cost-effectiveness analysis to identify what is the most useful initial test for patients with the suspicion of obstructive CAD in 2020.
SLIDE 7: We performed a cost-effectiveness analysis using real-world patients enrolled in the PROMISE trial to determine whether anatomical versus functional assessment is the best noninvasive testing strategy for patients with suspected obstructive coronary artery disease.
We determined lifetime rates of coronary revascularization and cardiovascular events, as well as lifetime costs and cost-effectiveness.
SLIDE 8: Over a lifetime, anatomical testing had a lower rate of revascularization, lower rate of CV events and was cheaper, which result was observed due to the ability to tailor statin therapy to the presence and extent of coronary artery disease.
Therefore, overall, our analysis suggests that anatomic-first strategies are cost-effective over a lifetime as compared to functional testing and may present a favorable initial diagnostic option in the evaluation of low-risk stable chest pain.
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