Cost-effectiveness of non-invasive imaging guided strategy vs fractional flow reserve guided approach in patients with non-culprit lesion at primary percutaneous coronary intervention

Abstract

Background: It is estimated that nearly 40% of the patients presenting with ST Elevation Myocardial Infarction (STEMI) have multivessel disease (MVD). The best strategy for STEMI patients with MVD is still not well established. Currently both the ESC and the ACC/AHA guidelines recommend revascularization of the culprit artery only with a further non-invasive or a staged revascularisation approach. Aim: To determine the cost effectiveness of non-invasive imaging guided strategy as compared to fractional flow reserve (FFR) guided approach in STEMI patients with significant MVD treated with Primary PCI (PPCI) of the culprit lesion. Methods: In this retrospective observational study, performed at a tertiary centre in the South-West of England, data were collected on consecutive patients who underwent PPCI from 1st Jul 2011 to 30 June 2012. A non-culprit lesion was considered to be significant if the stenosis was >50% in large proximal epicardial vessel or >70% elsewhere. The management of MVD was recorded. Results: 593 patients were included, out of these, 74% were males with a mean age of 63 years. Significant MVD was present in 188 patients (32%). At approximately 6 weeks from the acute event, 115/188 (61%) either underwent stress echocardiogram (n=68, 59%) or stress CMR (n=47, 41%). The remaining 73 patients either underwent direct revascularisation without any ischaemia assessment due to presence of critical stenosis (>95% stenosis) or died in hospital or were lost to follow up. Of those patients undergoing non-invasive imaging, 56% (64/115) had no evidence of inducible ischaemia, and were therefore treated conservatively. Putting these figures in a FFR guided approach model our study showed an average saving of {pound}285 per patient. This cost effectiveness calculation is based on the assumption that the positive and negative predictive value of non-invasive imaging and FFR assessment are similar. The model used a cost for a non invasive imaging test of {pound}550 (stress MRI - {pound}600, stress echo -{pound}500), angiography with FFR assessment {pound}1500, for elective angioplasty {pound}2500 and additional cost of angioplasty following on from FFR study of {pound}1000. Conclusion: Our study demonstrated that, when patients with MVD are selected with non-invasive imaging guided strategy, less than 50% patients undergoing PPCI with by-stander non-culprit coronary artery disease need further revascularisation. The results of our study suggest that non-invasive guided approach is both a feasible and cost-effective management strategy in patients with MVD following PPCI.