Comparative cost-effectiveness of non-invasive imaging tests in patients presenting with chronic stable chest pain with suspected coronary artery disease: a systematic review

Coronary artery disease (CAD) remains one of the leading causes of morbidity and mortality globally. The most cost-effective imaging strategy to diagnose CAD in patients with stable chest pain is however uncertain. To review the evidence on comparative cost-effectiveness of different imaging strategies for patients presenting with stable chest pain symptoms suggestive for CAD. Systematic review. Studies performing a formal economic evaluation or decision analysis in the English language published between January 1995 and December 2015 were identified using PubMed, Medline (OvidSP), Embase, Web of Science, Cochrane economic evaluations library, and EconLit. Reviews and meta-analyses were excluded. Two independent reviewers assessed titles and abstracts. Of the 4498 titles identified, 70 met our selection criteria. One reviewer used a modified version of the CHEERS checklist to assess study quality. One reviewer extracted data on study details, which were checked by a second reviewer. There is a major heterogeneity between the available cost-effectiveness studies included in this study. The included studies compared very different testing strategies in very different ways and provided mostly short-term results. Strategies of no-testing and xECG were underrepresented. Nonetheless, the findings from this systematic review suggest that for patients with a low to intermediate prior probability of having obstructive CAD, computed tomography coronary angiography (CTCA) may be cost-effective as an initial diagnostic imaging test in comparison with CAG or other non-invasive diagnostic tests. If functional testing is required, stress echocardiography (SE) or singlephoton emission computed tomography (SPECT) are suggested to be cost-effective initial strategies in patients with intermediate prior probability of CAD. Yet, other functional testing strategies such as xECG and positron-emission tomography (PET) scanning have not been studied as intensely. Immediate CAG is suggested to be a cost-effective strategy for patients at a high prior probability of having obstructive CAD whom may benefit from revascularization. The study emphasizes the inextricable link between clinical effectiveness and economic efficiency. Evidence suggests that the optimal diagnostic imaging strategy for individuals suspected of having CAD is CTCA for low and intermediate disease probability, followed by SE or SPECT as necessary, and invasive CAG for high disease probability. Further studies are needed to evaluate the cost-effectiveness of alternative non-invasive tests, including a no-testing strategy.