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Original research
Cost-effectiveness of cardiovascular imaging for stable coronary heart disease
  1. Simon Walker1,
  2. Edward Cox1,
  3. Ben Rothwell2,
  4. Colin Berry3,
  5. Gerry P McCann4,5,
  6. Chiara Bucciarelli-Ducci6,
  7. Erica Dall’Armellina7,8,
  8. Abhiram Prasad9,10,
  9. James Robert John Foley7,
  10. Kenneth Mangion3,
  11. Petra Bijsterveld11,
  12. Colin Everett11,
  13. Deborah Stocken11,
  14. Sven Plein7,
  15. John P Greenwood7,
  16. Mark Sculpher1
  1. 1 Centre for Health Economics, University of York, York, UK
  2. 2 RTI Health Solutions Manchester, Manchester, UK
  3. 3 Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
  4. 4 Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
  5. 5 NIHR Leicester Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester, UK
  6. 6 Bristol Heart Institute, NIHR Bristol Cardiovascular Biomedical Research Centre and Clinical Research and Imaging Centre (CRIC), University of Bristol and University Hospitals Bristol NHD Trust, Bristol, UK
  7. 7 Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular & Metabolic Medicine, University of Leeds, Leeds, UK
  8. 8 Oxford Centre of Cardiovascular Magnetic Resonance, Oxford University, Oxford, UK
  9. 9 Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
  10. 10 Cardiovascular Sciences Research Centre, St George's, University of London, London, UK
  11. 11 CTRU – Clinical Trials Research Unit, Leeds Institute for Clinical Trials Research, University of Leeds, Leeds, UK
  1. Correspondence to Simon Walker, Centre for Health Economics, University of York, York YO10 5DD, UK; simon.walker{at}


Objective To assess the cost-effectiveness of management strategies for patients presenting with chest pain and suspected coronary heart disease (CHD): (1) cardiovascular magnetic resonance (CMR); (2) myocardial perfusion scintigraphy (MPS); and (3) UK National Institute for Health and Care Excellence (NICE) guideline-guided care.

Methods Using UK data for 1202 patients from the Clinical Evaluation of Magnetic Resonance Imaging in Coronary Heart Disease 2 trial, we conducted an economic evaluation to assess the cost-effectiveness of CMR, MPS and NICE guidelines. Health outcomes were expressed as quality-adjusted life-years (QALYs), and costs reflected UK pound sterling in 2016–2017. Cost-effectiveness results were presented as incremental cost-effectiveness ratios and incremental net health benefits overall and for low, medium and high pretest likelihood of CHD subgroups.

Results CMR had the highest estimated QALY gain overall (2.21 (95% credible interval 2.15, 2.26) compared with 2.07 (1.92, 2.20) for NICE and 2.11 (2.01, 2.22) for MPS) and incurred comparable costs (overall £1625 (£1431, £1824) compared with £1753 (£1473, £2032) for NICE and £1768 (£1572, £1989) for MPS). Overall, CMR was the cost-effective strategy, being the dominant strategy (more effective, less costly) with incremental net health benefits per patient of 0.146 QALYs (−0.18, 0.406) compared with NICE guidelines at a cost-effectiveness threshold of £15 000 per QALY (93% probability of cost-effectiveness). Results were similar in the pretest likelihood subgroups.

Conclusions CMR-guided care is cost-effective overall and across all pretest likelihood subgroups, compared with MPS and NICE guidelines.

  • health care economics
  • cardiac magnetic resonance (CMR) imaging
  • cardiac imaging and diagnostics

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  • Correction notice This article has been corrected since it was published Online First. The data availability statement was updated, John P Greenwood was updated to include the middle initial and ORCID IDs were added to the author list.

  • Contributors SW, EC, BR and MS developed and conducted the economic analysis with significant support and input throughout from JG. JG, SW, CB, GPM, PB, SP and MS were involved in the concept and design of the CE-MARC2 study. All authors were involved in the acquisition, analysis or interpretation of data. SW, EC, JG and MS were involved in the drafting of the manuscript. All authors were involved in the critical revision of the manuscript. All authors have seen and approved the manuscript and have contributed significantly to the work.

  • Funding This analysis was funded by grant SP/12/1/29062 and fellowships FS/15/54/31639 (KM) and FS/1062/28409 (SP) from the British Heart Foundation; the Leeds Teaching Hospitals Charitable Foundation and the National Institute for Health Research (NIHR), through the Local Clinical Research Networks and the Leeds Clinical Research Facility; the NIHR Biomedical Research Unit in Cardiovascular Disease at the University Hospitals Bristol National Health Service Foundation Trust and the University of Bristol (CB-D); by a senior fellowship from the Scottish Funding Council and grant RE/13/5/30177 from the British Heart Foundation Centre of Research Excellence award (CB); and by NIHR Postdoctoral and Career Development Fellowships (GPM).

  • Competing interests CB is employed by the University of Glasgow, which holds research and/or consultancy agreements with AstraZeneca, Abbott Vascular, Boehringer Ingelheim, GSK, HeartFlow, Opsens and Novartis.

  • Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

  • Patient consent for publication Not required.

  • Ethics approval The study was conducted in accordance with the protocol which was approved by the UK National Research Ethics Service (12/YH/0404) and the institutional review boards of participating centres.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data supporting this publication are available on reasonable request. All requests will be reviewed by relevant stakeholders, based on principles of controlled data access. Requests to access data should be made to CTRU-DataAccess{at} in the first instance.