P6025A management strategy based on exercise echocardiography is more cost-effective than exercise ecg in patients presenting with suspected angina during long term follow up: a randomised study

Abstract

New onset stable chest pain is a widespread clinical problem. Although Exercise ECG (Ex-ECG) is advocated by European Society of Cardiology guidelines for patients with low to intermediate risk, there have been no randomized studies comparing Ex-ECG with exercise functional imaging that have evaluated long term healthcare costs and clinical outcomes. We present the long term results of the first randomized study of Ex-ECG and exercise stress echocardiography (ESE). Method(s): From February 2013 to March 2014, 385 patients with (i) no prior coronary artery disease (CAD),(ii) normal resting ECG and (iii) low-intermediate pretest probability of CAD, were randomized to undergo either Ex-ECG (194 patients) or ESE (191 patients). The mean age was 55+/-11 years, 68% were male and mean pretest probability of CAD was 34%, with no significant difference be- tween the 2 groups. During a mean of follow up of 3.0 years, the pre-specified, combined endpoint of death, non-fatal myocardial infarction, late revascularization and hospitalization for chest pain occurred in 26 patients in the Ex-ECG arm (3.7%) and 20 patients in the SE arm (3.2%) (hazard ratio, 1.15; 95% confidence interval [CI], 0.39 to 3.43; P=0.38). Resource consumption data were collected on emergency department visits, days in hospital, specialist clinic review, coronary angiography and coronary revascularization procedures. In total, 26 patients in the Ex-ECG arm and 12 patients in the ESE arm underwent invasive angiography (13.4% vs 6.3%, p=0.02) (Fig 1). At 1 year, the mean cost difference between the groups was 81.31. In year 2, the mean cost difference increased by 34.42, and in year 3, the mean cost difference increased further by 19.29. The overall cumulative costs for the entire duration of follow up were 154,382 for Ex-ECG and 120,425 for ESE, giving a unit cost of 796 and 631 respectively (p=0.04). This equated to a greater than 20% reduction in cost with an ESE strategy. Conclusion(s): In patients with suspected angina, an ESE management strategy is significantly more cost-effective than Ex-ECG during long term follow up, and leads to less invasive angiography. ESE and not Ex-ECG should be the first line test in suspected CAD which has implications on the present guidelines.