Original Research7 April 2015
A Cost-Effectiveness Analysis
    Author, Article, and Disclosure Information



    The optimal imaging strategy for patients with stable chest pain is uncertain.


    To determine the cost-effectiveness of different imaging strategies for patients with stable chest pain.


    Microsimulation state-transition model.

    Data Sources:

    Published literature.

    Target Population:

    60-year-old patients with a low to intermediate probability of coronary artery disease (CAD).

    Time Horizon:



    The United States, the United Kingdom, and the Netherlands.


    Coronary computed tomography (CT) angiography, cardiac stress magnetic resonance imaging, stress single-photon emission CT, and stress echocardiography.

    Outcome Measures:

    Lifetime costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios.

    Results of Base-Case Analysis:

    The strategy that maximized QALYs and was cost-effective in the United States and the Netherlands began with coronary CT angiography, continued with cardiac stress imaging if angiography found at least 50% stenosis in at least 1 coronary artery, and ended with catheter-based coronary angiography if stress imaging induced ischemia of any severity. For U.K. men, the preferred strategy was optimal medical therapy without catheter-based coronary angiography if coronary CT angiography found only moderate CAD or stress imaging induced only mild ischemia. In these strategies, stress echocardiography was consistently more effective and less expensive than other stress imaging tests. For U.K. women, the optimal strategy was stress echocardiography followed by catheter-based coronary angiography if echocardiography induced mild or moderate ischemia.

    Results of Sensitivity Analysis:

    Results were sensitive to changes in the probability of CAD and assumptions about false-positive results.


    All cardiac stress imaging tests were assumed to be available. Exercise electrocardiography was included only in a sensitivity analysis. Differences in QALYs among strategies were small.


    Coronary CT angiography is a cost-effective triage test for 60-year-old patients who have nonacute chest pain and a low to intermediate probability of CAD.

    Primary Funding Source:

    Erasmus University Medical Center.


    • 1. Wolk MJBailey SRDoherty JUDouglas PSHendel RCKramer CMet alAmerican College of Cardiology Foundation Appropriate Use Criteria Task ForceACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. J Am Coll Cardiol2014;63:380-406. [PMID: 24355759] doi:10.1016/j.jacc.2013.11.009 CrossrefMedlineGoogle Scholar
    • 2. Fihn SDGardin JMAbrams JBerra KBlankenship JCDallas APet alAmerican College of Cardiology Foundation2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation2012;126:3097-137. [PMID: 23166210] doi:10.1161/CIR.0b013e3182776f83 CrossrefMedlineGoogle Scholar
    • 3. Fox KGarcia MAArdissino DBuszman PCamici PGCrea Fet alTask Force on the Management of Stable Angina Pectoris of the European Society of CardiologyGuidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. Eur Heart J2006;27:1341-81. [PMID: 16735367] CrossrefMedlineGoogle Scholar
    • 4. Cooper A, Calvert N, Skinner J, Sawyer L, Sparrow K, Timmis A, et al. Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. London: National Institute for Health and Care Excellence; 2010:9. Accessed at www.nice.org.uk/guidance/cg95/chapter/guidance on 26 January 2015. Google Scholar
    • 5. Mudrick DWCowper PAShah BRPatel MRJensen NCPeterson EDet alDownstream procedures and outcomes after stress testing for chest pain without known coronary artery disease in the United States. Am Heart J2012;163:454-61. [PMID: 22424017] doi:10.1016/j.ahj.2011.11.022 CrossrefMedlineGoogle Scholar
    • 6. Patel MRPeterson EDDai DBrennan JMRedberg RFAnderson HVet alLow diagnostic yield of elective coronary angiography. N Engl J Med2010;362:886-95. [PMID: 20220183] CrossrefMedlineGoogle Scholar
    • 7. Mowatt GCook JAHillis GSWalker SFraser CJia Xet al64-Slice computed tomography angiography in the diagnosis and assessment of coronary artery disease: systematic review and meta-analysis. Heart2008;94:1386-93. [PMID: 18669550] doi:10.1136/hrt.2008.145292 CrossrefMedlineGoogle Scholar
    • 8. Schuetz GMZacharopoulou NMSchlattmann PDewey MMeta-analysis: noninvasive coronary angiography using computed tomography versus magnetic resonance imaging. Ann Intern Med2010;152:167-77. [PMID: 20124233] doi:10.7326/0003-4819-152-3-201002020-00008 LinkGoogle Scholar
    • 9. von Ballmoos MWHaring BJuillerat PAlkadhi HMeta-analysis: diagnostic performance of low-radiation-dose coronary computed tomography angiography. Ann Intern Med2011;154:413-20. [PMID: 21403076] doi:10.7326/0003-4819-154-6-201103150-00007 LinkGoogle Scholar
    • 10. Groothuis JGBeek AMBrinckman SLMeijerink MRKoestner SCNijveldt Ret alLow to intermediate probability of coronary artery disease: comparison of coronary CT angiography with first-pass MR myocardial perfusion imaging. Radiology2010;254:384-92. [PMID: 20089723] doi:10.1148/radiol.09090802 CrossrefMedlineGoogle Scholar
    • 11. Meijboom WBVan Mieghem CAvan Pelt NWeustink APugliese FMollet NRet alComprehensive assessment of coronary artery stenoses: computed tomography coronary angiography versus conventional coronary angiography and correlation with fractional flow reserve in patients with stable angina. J Am Coll Cardiol2008;52:636-43. [PMID: 18702967] doi:10.1016/j.jacc.2008.05.024 CrossrefMedlineGoogle Scholar
    • 12. Hamon MFau GNée GEhtisham JMorello RHamon MMeta-analysis of the diagnostic performance of stress perfusion cardiovascular magnetic resonance for detection of coronary artery disease. J Cardiovasc Magn Reson2010;12:29. [PMID: 20482819] doi:10.1186/1532-429X-12-29 CrossrefMedlineGoogle Scholar
    • 13. Greenwood JPMaredia NYounger JFBrown JMNixon JEverett CCet alCardiovascular magnetic resonance and single-photon emission computed tomography for diagnosis of coronary heart disease (CE-MARC): a prospective trial. Lancet2012;379:453-60. [PMID: 22196944] doi:10.1016/S0140-6736(11)61335-4 CrossrefMedlineGoogle Scholar
    • 14. Jaarsma CLeiner TBekkers SCCrijns HJWildberger JENagel Eet alDiagnostic performance of noninvasive myocardial perfusion imaging using single-photon emission computed tomography, cardiac magnetic resonance, and positron emission tomography imaging for the detection of obstructive coronary artery disease: a meta-analysis. J Am Coll Cardiol2012;59:1719-28. [PMID: 22554604] doi:10.1016/j.jacc.2011.12.040 CrossrefMedlineGoogle Scholar
    • 15. Schwitter JWacker CMvan Rossum ACLombardi MAl-Saadi NAhlstrom Het alMR-IMPACT: comparison of perfusion-cardiac magnetic resonance with single-photon emission computed tomography for the detection of coronary artery disease in a multicentre, multivendor, randomized trial. Eur Heart J2008;29:480-9. [PMID: 18208849] doi:10.1093/eurheartj/ehm617 CrossrefMedlineGoogle Scholar
    • 16. de Jong MCGenders TSvan Geuns RJMoelker AHunink MGDiagnostic performance of stress myocardial perfusion imaging for coronary artery disease: a systematic review and meta-analysis. Eur Radiol2012;22:1881-95. [PMID: 22527375] doi:10.1007/s00330-012-2434-1 CrossrefMedlineGoogle Scholar
    • 17. Heijenbrok-Kal MHFleischmann KEHunink MGStress echocardiography, stress single-photon-emission computed tomography and electron beam computed tomography for the assessment of coronary artery disease: a meta-analysis of diagnostic performance. Am Heart J2007;154:415-23. [PMID: 17719283] CrossrefMedlineGoogle Scholar
    • 18. Mettler FAHuda WYoshizumi TTMahesh MEffective doses in radiology and diagnostic nuclear medicine: a catalog. Radiology2008;248:254-63. [PMID: 18566177] doi:10.1148/radiol.2481071451 CrossrefMedlineGoogle Scholar
    • 19. Katayama HYamaguchi KKozuka TTakashima TSeez PMatsuura KAdverse reactions to ionic and nonionic contrast media. A report from the Japanese Committee on the Safety of Contrast Media. Radiology1990;175:621-8. [PMID: 2343107] CrossrefMedlineGoogle Scholar
    • 20. Noto TJJohnson LWKrone RWeaver WFClark DAKramer JRet alCardiac catheterization 1990: a report of the Registry of the Society for Cardiac Angiography and Interventions (SCA&I). Cathet Cardiovasc Diagn1991;24:75-83. [PMID: 1742788] CrossrefMedlineGoogle Scholar
    • 21. Scanlon PJFaxon DPAudet AMCarabello BDehmer GJEagle KAet alACC/AHA guidelines for coronary angiography. A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on Coronary Angiography). Developed in collaboration with the Society for Cardiac Angiography and Interventions. J Am Coll Cardiol1999;33:1756-824. [PMID: 10334456] MedlineGoogle Scholar
    • 22. Gold MRSiegel JERussell LBWeinstein MCCost-Effectiveness in Health and Medicine. New York: Oxford Univ Pr; 1996. Google Scholar
    • 23. Siegel JEWeinstein MCRussell LBGold MRRecommendations for reporting cost-effectiveness analyses. Panel on Cost-Effectiveness in Health and Medicine. JAMA1996;276:1339-41. [PMID: 8861994] CrossrefMedlineGoogle Scholar
    • 24. Weinstein MCSiegel JEGold MRKamlet MSRussell LBRecommendations of the Panel on Cost-effectiveness in Health and Medicine. JAMA1996;276:1253-8. [PMID: 8849754] CrossrefMedlineGoogle Scholar
    • 25. National Institute for Health and Care Excellence. Guide to the methods of technology appraisal. London: National Institute for Health and Care Excellence; 2008:41, 57-60. Accessed at www.nice.nhs.uk/media/B52/A7/TAMethodsGuideUpdatedJune2008.pdf on 28 August 2013. Google Scholar
    • 26. Hakkaart-van Roijen LTan SSBouwmans C[Dutch Manual for Cost Analysis]. Diemen, the Netherlands: Dutch Health Care Insurance Board; 2010:17, 87-8. Google Scholar
    • 27. Council for Public Health and Health Care. Sensible and Sustainable Care. The Hague, the Netherlands: Council for Public Health and Health Care; 2006:5. Accessed at http://rvz.net/uploads/docs/Sensible_and_sustainable_care.pdf on 15 December 2011. Google Scholar
    • 28. Machaalany JYam YRuddy TDAbraham AChen LBeanlands RSet alPotential clinical and economic consequences of noncardiac incidental findings on cardiac computed tomography. J Am Coll Cardiol2009;54:1533-41. [PMID: 19815125] doi:10.1016/j.jacc.2009.06.026 CrossrefMedlineGoogle Scholar
    • 29. Budoff MJGopal AGul KMMao SSFischer HOudiz RJPrevalence of obstructive coronary artery disease in an outpatient cardiac CT angiography environment. Int J Cardiol2008;129:32-6. [PMID: 17651836] CrossrefMedlineGoogle Scholar
    • 30. Deckers JWGoedhart DMBoersma EBriggs ABertrand MFerrari Ret alTreatment benefit by perindopril in patients with stable coronary artery disease at different levels of risk. Eur Heart J2006;27:796-801. [PMID: 16497685] CrossrefMedlineGoogle Scholar
    • 31. Hanmer JLawrence WFAnderson JPKaplan RMFryback DGReport of nationally representative values for the noninstitutionalized US adult population for 7 health-related quality-of-life scores. Med Decis Making2006;26:391-400. [PMID: 16855127] CrossrefMedlineGoogle Scholar
    • 32. Weintraub WSSpertus JAKolm PMaron DJZhang ZJurkovitz Cet alCOURAGE Trial Research GroupEffect of PCI on quality of life in patients with stable coronary disease. N Engl J Med2008;359:677-87. [PMID: 18703470] doi:10.1056/NEJMoa072771 CrossrefMedlineGoogle Scholar
    • 33. Cohen DJVan Hout BSerruys PWMohr FWMacaya Cden Heijer Pet alSynergy between PCI with Taxus and Cardiac Surgery InvestigatorsQuality of life after PCI with drug-eluting stents or coronary-artery bypass surgery. N Engl J Med2011;364:1016-26. [PMID: 21410370] doi:10.1056/NEJMoa1001508 CrossrefMedlineGoogle Scholar
    • 34. Genders TSSteyerberg EWHunink MGNieman KGalema TWMollet NRet alPrediction model to estimate presence of coronary artery disease: retrospective pooled analysis of existing cohorts. BMJ2012;344:e3485. [PMID: 22692650] doi:10.1136/bmj.e3485 CrossrefMedlineGoogle Scholar
    • 35. Moschetti KMuzzarelli SPinget CWagner APilz GWasserfallen JBet alCost evaluation of cardiovascular magnetic resonance versus coronary angiography for the diagnostic work-up of coronary artery disease: application of the European Cardiovascular Magnetic Resonance registry data to the German, United Kingdom, Swiss, and United States health care systems. J Cardiovasc Magn Reson2012;14:35. [PMID: 22697303] doi:10.1186/1532-429X-14-35 CrossrefMedlineGoogle Scholar
    • 36. Min JKGilmore ABudoff MJBerman DSO'Day KCost-effectiveness of coronary CT angiography versus myocardial perfusion SPECT for evaluation of patients with chest pain and no known coronary artery disease. Radiology2010;254:801-8. [PMID: 20177094] doi:10.1148/radiol.09090349 CrossrefMedlineGoogle Scholar
    • 37. Shreibati JBBaker LCHlatky MAAssociation of coronary CT angiography or stress testing with subsequent utilization and spending among Medicare beneficiaries. JAMA2011;306:2128-36. [PMID: 22089720] doi:10.1001/jama.2011.1652 CrossrefMedlineGoogle Scholar
    • 38. Kwok YKim CGrady DSegal MRedberg RMeta-analysis of exercise testing to detect coronary artery disease in women. Am J Cardiol1999;83:660-6. [PMID: 10080415] CrossrefMedlineGoogle Scholar
    • 39. Walker SGirardin FMcKenna CBall SGNixon JPlein Set alCost-effectiveness of cardiovascular magnetic resonance in the diagnosis of coronary heart disease: an economic evaluation using data from the CE-MARC study. Heart2013;99:873-81. [PMID: 23591668] doi:10.1136/heartjnl-2013-303624 CrossrefMedlineGoogle Scholar
    • 40. Genders TSFerket BSDedic AGalema TWMollet NRde Feyter PJet alCoronary computed tomography versus exercise testing in patients with stable chest pain: comparative effectiveness and costs. Int J Cardiol2013;167:1268-75. [PMID: 22520158] doi:10.1016/j.ijcard.2012.03.151 CrossrefMedlineGoogle Scholar
    • 41. Hachamovitch RBerman DSKiat HCohen IFriedman JDShaw LJValue of stress myocardial perfusion single photon emission computed tomography in patients with normal resting electrocardiograms: an evaluation of incremental prognostic value and cost-effectiveness. Circulation2002;105:823-9. [PMID: 11854122] CrossrefMedlineGoogle Scholar
    • 42. Fearon WFBornschein BTonino PAGothe RMBruyne BDPijls NHet alFractional Flow Reserve Versus Angiography for Multivessel Evaluation (FAME) Study InvestigatorsEconomic evaluation of fractional flow reserve-guided percutaneous coronary intervention in patients with multivessel disease. Circulation2010;122:2545-50. [PMID: 21126973] doi:10.1161/CIRCULATIONAHA.109.925396 CrossrefMedlineGoogle Scholar
    • 43. Dutch National Authority of Health Care. [Dutch Tariffs for Health Care Products]. Utrecht, the Netherlands: Dutch National Authority of Health Care; 2008. Accessed at http://dbc-zorgproducten-tarieven.nza.nl/nzaZpTarief/ZoekfunctieDbc.aspx on 25 November 2011. Google Scholar
    • 44. Agency for Healthcare Research and Quality. HCUPnet Web site. Accessed at http://hcupnet.ahrq.gov on 17 November 2011. Google Scholar
    • 45. National Health Service. Electronic Drug Tariff. London: United Kingdom Department of Health; 2011. Accessed at www.ppa.org.uk/ppa/edt_intro.htm on 10 November 2011. Google Scholar
    • 46. Van Loenen A. [Pharmacotherapeutic Compass]. Diemen, the Netherlands: Dutch Health Care Insurance Board; 2011. Accessed at http://fk.cvz.nl on 15 December 2011. Google Scholar
    • 47. Lazar LDPletcher MJCoxson PGBibbins-Domingo KGoldman LCost-effectiveness of statin therapy for primary prevention in a low-cost statin era. Circulation2011;124:146-53. [PMID: 21709063] doi:10.1161/CIRCULATIONAHA.110.986349 CrossrefMedlineGoogle Scholar
    • 48. Bravata DMGienger ALMcDonald KMSundaram VPerez MVVarghese Ret alSystematic review: the comparative effectiveness of percutaneous coronary interventions and coronary artery bypass graft surgery. Ann Intern Med2007;147:703-16. [PMID: 17938385] doi:10.7326/0003-4819-147-10-200711200-00185 LinkGoogle Scholar
    • 49. Genders TSMeijboom WBMeijs MFSchuijf JDMollet NRWeustink ACet alCT coronary angiography in patients suspected of having coronary artery disease: decision making from various perspectives in the face of uncertainty. Radiology2009;253:734-44. [PMID: 19864509] doi:10.1148/radiol.2533090507 CrossrefMedlineGoogle Scholar
    • 50. Hulten EACarbonaro SPetrillo SPMitchell JDVillines TCPrognostic value of cardiac computed tomography angiography: a systematic review and meta-analysis. J Am Coll Cardiol2011;57:1237-47. [PMID: 21145688] doi:10.1016/j.jacc.2010.10.011 CrossrefMedlineGoogle Scholar
    • 51. Boden WEO'Rourke RATeo KKHartigan PMMaron DJKostuk WJet alCOURAGE Trial Research GroupOptimal medical therapy with or without PCI for stable coronary disease. N Engl J Med2007;356:1503-16. [PMID: 17387127] CrossrefMedlineGoogle Scholar
    • 52. Kappetein APFeldman TEMack MJMorice MCHolmes DRStåhle Eet alComparison of coronary bypass surgery with drug-eluting stenting for the treatment of left main and/or three-vessel disease: 3-year follow-up of the SYNTAX trial. Eur Heart J2011;32:2125-34. [PMID: 21697170] doi:10.1093/eurheartj/ehr213 CrossrefMedlineGoogle Scholar
    • 53. Serruys PWMorice MCKappetein APColombo AHolmes DRMack MJet alSYNTAX InvestigatorsPercutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med2009;360:961-72. [PMID: 19228612] doi:10.1056/NEJMoa0804626 CrossrefMedlineGoogle Scholar
    • 54. Nieman KGalema TWeustink ANeefjes LMoelker AMusters Pet alComputed tomography versus exercise electrocardiography in patients with stable chest complaints: real-world experiences from a fast-track chest pain clinic. Heart2009;95:1669-75. [PMID: 19622516] doi:10.1136/hrt.2009.169441 CrossrefMedlineGoogle Scholar
    • 55. Berger JSBrown DLBecker RCLow-dose aspirin in patients with stable cardiovascular disease: a meta-analysis. Am J Med2008;121:43-9. [PMID: 18187072] doi:10.1016/j.amjmed.2007.10.002 CrossrefMedlineGoogle Scholar
    • 56. Dagenais GRPogue JFox KSimoons MLYusuf SAngiotensin-converting-enzyme inhibitors in stable vascular disease without left ventricular systolic dysfunction or heart failure: a combined analysis of three trials. Lancet2006;368:581-8. [PMID: 16905022] CrossrefMedlineGoogle Scholar
    • 57. Vokó Zde Brouwer SLubsen JDanchin NOtterstad JEDunselman PHet alLong-term impact of secondary preventive treatments in patients with stable angina. Eur J Epidemiol2011;26:375-83. [PMID: 21336804] doi:10.1007/s10654-011-9558-5 CrossrefMedlineGoogle Scholar
    • 58. Daly CAClemens FSendon JLTavazzi LBoersma EDanchin Net alEuro Heart Survey InvestigatorsThe initial management of stable angina in Europe, from the Euro Heart Survey: a description of pharmacological management and revascularization strategies initiated within the first month of presentation to a cardiologist in the Euro Heart Survey of Stable Angina. Eur Heart J2005;26:1011-22. [PMID: 15716284] MedlineGoogle Scholar
    • 59. Dedic AGenders TSFerket BSGalema TWMollet NRMoelker Aet alStable angina pectoris: head-to-head comparison of prognostic value of cardiac CT and exercise testing. Radiology2011;261:428-36. [PMID: 21873254] doi:10.1148/radiol.11110744 CrossrefMedlineGoogle Scholar
    • 60. Arias E. United States Life Tables, 2007. Atlanta, GA: Centers for Disease Control and Prevention; 2007. Accessed at www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_09.pdf on 15 November 2011. Google Scholar
    • 61. Office for National Statistics. United Kingdom Interim Life Tables, 2008–2010. London: Office for National Statistics; 2010. Accessed at www.ons.gov.uk/ons/taxonomy/index.html?nscl=Interim+Life+Tables on 15 November 2011. Google Scholar
    • 62. Dutch Central Bureau of Statistics. Life Tables 2010. The Hague, the Netherlands: Dutch Central Bureau of Statistics; 2010. Accessed at http://statline.cbs.nl/Statweb/publication/?DM=SLNL&PA=37360NED&D1=0&D2=a&D3=a&D4=60&HDR=G1,T,G3&STB=G2&VW=T on 15 November 2011. Google Scholar
    • 63. Ara RBrazier JDeriving an algorithm to convert the eight mean SF-36 dimension scores into a mean EQ-5D preference-based score from published studies (where patient level data are not available). Value Health2008;11:1131-43. [PMID: 18489495] doi:10.1111/j.1524-4733.2008.00352.x CrossrefMedlineGoogle Scholar
    • 64. Pletcher MJLazar LBibbins-Domingo KMoran ARodondi NCoxson Pet alComparing impact and cost-effectiveness of primary prevention strategies for lipid-lowering. Ann Intern Med2009;150:243-54. [PMID: 19221376] doi:10.7326/0003-4819-150-4-200902170-00005 LinkGoogle Scholar