Comparison of the cost-effectiveness of stress myocardial SPECT and stress echocardiography in suspected coronary artery disease considering the prognostic value of false-negative results

doi:10.1067/mnc.2002.125217

Journal of Nuclear Cardiology

Volume 9, Issue 5, September 2002, Pages 515-522

https://doi.org/10.1067/mnc.2002.125217 Get rights and content

Abstract

Background. The prognoses of patients with false-negative test results by myocardial single photon emission computed tomography (SPECT) and by stress echocardiography are known to be different; the prognosis with false-negative SPECT is better in suspected and proven coronary artery disease (CAD). Methods and Results. Three strategies by which to diagnose CAD were compared for their cost-effectiveness when considering the prognostic value of false-negative results: (1) stress myocardial SPECT by dipyridamole or adenosine followed by coronary angiography (CAG), (2) exercise stress echocardiography followed by CAG, and (3) dobutamine stress echocardiography followed by CAG. Delta quality-adjusted life-year (QALY) was calculated for the three strategies separately when annual mortality and infarction rates were 0.5% and 0.5% for myocardial SPECT and 2% and 2% for stress echocardiography, respectively. Costs were estimated and costs per ΔQALY were calculated according to the pretest likelihood of CAD (pCAD). The myocardial SPECT followed by CAG strategy was the most cost-effective in the patients with a pCAD of 0.3 or greater, and the dobutamine echocardiography followed by CAG strategy was the most cost-effective in patients with a pCAD of 0.2 or lower. This was the case when we assumed that the nondiagnostic test rate of dobutamine echocardiography was 9% (in contrast to 0% by myocardial SPECT and 18% by exercise echocardiography). Sensitivity analysis showed that the cost-effectiveness of dobutamine echocardiography followed by CAG was best only if the prognosis of false-negative results of dobutamine echocardiography was better. The cost-effectiveness of exercise echocardiography was dubious because of the high nondiagnostic rate with inadequate exercise. Conclusions. When the lower event rates of (false) negative SPECT were considered, the relatively expensive myocardial SPECT strategy was more cost-effective than the cheaper stress echocardiography strategy in patients with a pCAD of 0.3 or greater. According to sensitivity analysis, the prognostic value of false-negative results and the nondiagnostic test rate were important determinants of stress myocardial study cost-effectiveness. (J Nucl Cardiol 2002;9:515-22)

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Cited by (33)

Cost-Effectiveness and Future Implications for Cardiovascular Imaging
2013, Canadian Journal of Cardiology
Citation Excerpt :
Simplistic examples of cost savings associated with index procedural costs can be short-sighted because there can be downstream-induced costs that offset any initial savings within a given episode of care. For example, within the diagnostic work-up of patients with suspected coronary artery disease (CAD), stress echocardiography27-29 or electrocardiography (ECG)26 are lower cost procedures when compared with stress myocardial perfusion single-photon emission CT (SPECT) or CMR. In a recent example, the lower cost, exercise ECG resulted in approximately 12% of women proceeding to a follow-up, myocardial perfusion SPECT scan at 1 year of follow-up.26
This review highlights the current economic climate for health care and the evidentiary standards that are increasingly applied to appropriate use of cardiovascular imaging. Additionally, the evidence on cost efficiency and effectiveness is explored in this review. Ongoing multicentre registries and clinical trials will further enrich this evidence base with regard to value-based imaging strategies that provide enhanced effectiveness and efficiency resulting in improved patient outcomes.
Cette revue souligne le climat économique actuel des soins de santé et les normes en matière de preuves qui sont de plus en plus appliquées pour utiliser de manière appropriée l’imagerie cardiovasculaire. De plus, les données sur le rapport coût-efficacité y sont explorées. Les registres et les essais cliniques multicentriques en cours enrichiront davantage ce corpus de données scientifiques en ce qui concerne les stratégies d’imagerie basées sur la valeur qui offrent une meilleure efficacité et une meilleure efficience entraînant de meilleurs résultats pour le patient.
Cost-Effectiveness of Myocardial Perfusion Single-Photon Emission Computed Tomography
2010, Clinical Nuclear Cardiology: State of the Art and Future Directions
Cost-effectiveness of myocardial perfusion single-photon emission computed tomography
2010, Clinical Nuclear Cardiology
Comparison of gated SPECT with other imaging techniques used in cardiology
2008, Revista Espanola de Cardiologia Suplementos
Para el diagnóstico y la evaluación pronóstica de los pacientes con cardiopatía isquémica, además de la gated-SPECT se utilizan otras técnicas de imagen, como la ecocardiografía con sobrecarga, la tomografía computarizada (TC) y la resonancia magnética (RM).
La ecocardiografía con sobrecarga (ejercicio físico o sobrecarga farmacológica) es la más utilizada por el momento, dada su gran disponibilidad, inocuidad y versatilidad. Esta técnica tiene un valor parecido al de la gated-SPECT para detectar isquemia, con una menor sensibilidad y una mayor especificidad.
La TC puede usarse para detectar calcio, que mide la carga aterosclerótica total, pero no el grado de obstrucción coronaria, ya que las placas más calcificadas no necesariamente son las más obstructivas. A mayor cantidad de calcio, mayor probabilidad de lesiones coronarias importantes y peor pronóstico. La TC también puede usarse como angiografía no invasiva, si se inyecta contraste yodado y se hace una reconstrucción posterior de las arterias coronarias, tanto de forma longitudinal como transversal. Con los equipos habituales se necesita bradicardizar al paciente con un betabloqueante y no se puede hacer un buen estudio si hay cualquier tipo de arritmia.
La RM con gadolinio permite detectar infartos no transmurales con una alta fiabilidad. Además, facilita la evaluación completa de la anatomía y la función ventricular, así como los estudios de sobrecarga farmacológica para la detección de isquemia. Los principales problemas son su elevado coste y su menor disponibilidad respecto a las otras técnicas.
La tomografía por emisión de positrones (PET) se emplea de momento en investigación y muy poco en la clínica.
In addition to gated SPECT, a number of other imaging techniques are used in the diagnostic and prognostic assessment of patients with ischemic heart disease, such as stress echocardiography, computed tomography, and magnetic resonance imaging.
At present, stress echocardiography (involving physical exercise or pharmacological stress) is the most commonly used technique because it is readily available, safe and versatile. This technique is as valuable as gated SPECT for detecting ischemia, and has lower sensitivity and higher specificity.
Computed tomography (CT) can be used to detect calcium, thereby giving an estimate of the total atherosclerotic burden, but not of the degree of coronary obstruction, because the most calcified plaques are not necessarily the most obstructive. However, the greater the amount of calcium, the higher the probability that severe coronary lesions are present and the worse the prognosis. In addition, CT can also be used as a form of noninvasive angiography. Following the injection of iodine contrast, the anatomy of the coronary arteries can be reconstructed, both longitudinally and transversally. With currently available systems, it is necessary to administer a betablocker to induce bradycardia as the presence of any form of arrhythmia can prevent accurate imaging.
Magnetic resonance imaging (MRI) with gadolinium can detect non-transmural infarctions with great accuracy. Moreover, it can also provide a complete assessment of ventricular anatomy and function, and can be used to detect ischemia during pharmacological stress. The main disadvantages are that it is expensive and that it is less readily available than other techniques.
Currently, positron-emission tomography (PET) is mainly a research tool and is very seldom used clinically.
The Prognostic Value of Normal Exercise Myocardial Perfusion Imaging and Exercise Echocardiography. A Meta-Analysis
2007, Journal of the American College of Cardiology
Citation Excerpt :
Among these, 148 full-text articles evaluating the prognostic utility of exercise MPI or exercise echocardiography were reviewed, and 20 studies were found to be eligible for the systematic review. Of the 148 full-text articles reviewed, 17 did not address the research question (15–31), 18 were excluded because they used pharmacologic rather than exercise stress (32–49), 27 did not include primary data on event rates that could be combined in a meta-analysis (47,50–75), 16 did not address a population with known or suspected CAD (76–91), 5 evaluated only hospitalized patients or patients evaluated for chest pain syndromes in the emergency department (92–96), 16 included only patients with angiographically proven CAD or positive tests (97–112), 21 were potentially overlapping patient populations of other studies (53,113–132), 5 evaluated planar MPI (133–137), and 3 did not define a negative test as one without any abnormalities (138–140). Of the 17 studies included that evaluated MPI (141–156), 5 used thallium (143,147,153,154,157), 8 used sestamibi (141,142,146,148–150,152,156), 2 used both thallium and sestamibi (145,155), and 2 used tetrofosmin (144,151).
The purpose of this work was to determine the prognostic value of normal exercise myocardial perfusion imaging (MPI) tests and exercise echocardiography tests, and to determine the prognostic value of these imaging modalities in women and men.
Exercise MPI and exercise echocardiography provide prognostic information that is useful in the risk stratification of patients with suspected coronary artery disease (CAD).
We searched the PubMed, Cochrane, and DARE databases between January 1990 and May 2005, and reviewed bibliographies of articles obtained. We included prospective cohort studies of subjects who underwent exercise MPI or exercise echocardiography for known or suspected CAD, and provided data on primary outcomes of myocardial infarction (MI) and cardiac death with at least 3 months of follow-up. Secondary outcomes (unstable angina, revascularization procedures) were abstracted if provided. Studies performed exclusively in patients with CAD were excluded.
The negative predictive value (NPV) for MI and cardiac death was 98.8% (95% confidence interval [CI] 98.5 to 99.0) over 36 months of follow-up for MPI, and 98.4% (95% CI 97.9 to 98.9) over 33 months for echocardiography. The corresponding annualized event rates were 0.45% per year for MPI and 0.54% per year for echocardiography. In subgroup analyses, annualized event rates were <1% for each MPI isotope, and were similar for women and men. For secondary events, MPI and echocardiography had annualized event rates of 1.25% and 0.95%, respectively.
Both exercise MPI and exercise echocardiography have high NPVs for primary and secondary cardiac events. The prognostic utility of both modalities is similar for both men and women.
Nuclear cardiology, an evidence based sub-speciality
2006, Revista Espanola de Medicina Nuclear

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Original articleComparison of the cost-effectiveness of stress myocardial SPECT and stress echocardiography in suspected coronary artery disease considering the prognostic value of false-negative results

Abstract

Original article
Comparison of the cost-effectiveness of stress myocardial SPECT and stress echocardiography in suspected coronary artery disease considering the prognostic value of false-negative results