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Coronary artery disease
Original research article
The safety, efficacy and cost-effectiveness of stress echocardiography in patients with high pretest probability of coronary artery disease
  1. Alexandros Papachristidis1,
  2. Daniela Cassar Demarco1,
  3. Damian Roper1,
  4. Ioannis Tsironis1,
  5. Michael Papitsas1,
  6. Jonathan Byrne1,
  7. Khaled Alfakih1,2 and
  8. Mark J Monaghan1
  1. 1 Department of Cardiology, King’s College Hospital NHS Foundation Trust, Denmark Hill, London, UK
  2. 2 Department of Cardiology, Lewisham Healthcare NHS Trust, London, UK
  1. Correspondence to Dr. Alexandros Papachristidis; alexandros.papachristidis{at}nhs.net

Abstract

Objective In this study, we assess the clinical and cost-effectiveness of stress echocardiography (SE), as well as the place of SE in patients with high pretest probability (PTP) of coronary artery disease (CAD).

Methods We investigated 257 patients with no history of CAD, who underwent SE, and they had a PTP risk score >61% (high PTP). According to the National Institute for Health and Care Excellence guidance (NICE CG95, 2010), these patients should be investigated directly with an invasive coronary angiogram (ICA). We investigated those patients with SE initially and then with ICA when appropriate. Follow-up data with regard to Major Adverse Cardiac and Cerebrovascular Events (MACCE, defined as cardiovascular mortality, cerebrovascular accident (CVA), myocardial infarction (MI) and late revascularisation for acute coronary syndrome/unstable angina) were recorded for a period of 12 months following the SE. The tariff for SE and ICA is £300 and £1400, respectively.

Results 106 patients had a positive SE (41.2%) and 61 of them (57.5%) had further investigation with ICA. 15 (24.6%) of these patients were revascularised. The average cost per patient for investigations was £654.09. If NICE guidance had been followed, the cost would have been significantly higher at £1400 (p<0.001). Overall, 5 MACCE (2.0%) were recorded; 4 (3.8%) in the group of positive SE (2 CVAs and 2 MIs) and 1 (0.7%) in the group of negative SE (1 CVA). There was no MI and no need for revascularisation in the negative SE group.

Conclusion Our approach to investigate patients who present with de novo chest pain and high PTP, with SE initially and subsequently with ICA when appropriate, reduces the cost significantly (£745.91 per patient) with a very low rate of MACCE. However, this study is underpowered to assess safety of SE.

  • ECHOCARDIOGRAPHY
  • CORONARY ARTERY DISEASE
  • STRESS
  • CHEST PAIN CLINIC
  • RISK STRATIFICATION

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

https://doi.org/10.1136/openhrt-2017-000605

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    Footnotes

    • Contributors AP collected data, performed statistical analysis and interpretation of results and wrote the manuscript. DCD collected data and revised the manuscript. DR collected data and revised the manuscript. IT collected data and revised the manuscript. MP collected data and revised the manuscript. JB revised the manuscript and provided expert opinion throughout. KA conceived the idea for the project and revised the manuscript. MJM conceived the idea for the project, revised the manuscript and provided expert opinion throughout.

    • Funding This study was supported in part by a NationalInstitute for Health Research Biomedical Research Centre award to Guy's &St Thomas' Hospital and King's College London in partnership with King'sCollege Hospital (Grant Code: IS-BRC-1215-20006)

    • Competing interests None declared.

    • Patient consent Detail has been removed from this case description/these case descriptions to ensure anonymity. The editors and reviewers have seen the detailed information available and are satisfied that the information backs up the case the authors are making.

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