on December 31, 2001
Published online before print December 31, 2001, doi: 10.1161/hc0602.103584
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Submitted on June 26, 2001
From the VA Palo Alto Health Care System (P.G.B., S.C.,
B.C., P.W.L.), Palo Alto, Calif; Stanford University School of Medicine
(P.G.B., P.W.L., M.A.H.), Stanford, Calif; Syracuse VA Medical Center
(W.E.B.), Syracuse, NY; and VA Puget Sound Health Care System (N.R.E.),
Seattle, Wash. * To whom correspondence should be addressed. E-mail: hlatky{at}stanford.edu.
Background—Use
of coronary angiography after myocardial infarction has been
controversial, with some physicians advocating routine use and others
advocating selective use only after documentation of residual
myocardial ischemia. The effects of these strategies on
economic outcomes have not been
established. Methods and Results—We
analyzed data from a randomized, controlled clinical trial
conducted in 17 Department of Veterans Affairs hospitals that enrolled
876 clinically uncomplicated patients 24 to 72 hours after an acute
non--Q-wave myocardial infarction. The routine invasive strategy
included early coronary angiography with
revascularization based on established guidelines.
The conservative, ischemia-guided strategy included noninvasive
testing with radionuclide ventriculography and exercise thallium
scintigraphy, followed by coronary angiography in
patients with objective evidence of myocardial ischemia. We
measured the cost of hospitalization and outpatient visits and tests
during follow-up and calculated the incremental cost-effectiveness
ratio. The conservative, ischemia-guided strategy had lower
costs than the routine invasive strategy, both during the initial
hospitalization ($14 733 versus $19 256,
P<0.001) and after a mean
follow-up of 1.9 years ($39 707 versus $41 893,
P=0.04). The hazard ratio for
death was 0.72 (confidence limits, 0.51 to 1.01) in the conservative
strategy. The conservative strategy had lower costs and better outcomes
in 76% of 1000 bootstrap replications, and a cost-effectiveness ratio
below $50 000 per year of life added in 96% of
replications. Conclusions—A
conservative, ischemia-guided strategy of selective
coronary angiography and revascularization
for patients who develop objective evidence of recurrent
ischemia is more cost-effective than a strategy of routine
coronary angiography after uncomplicated non--Q-wave myocardial
infarction.
Revised on November 29, 2001
Accepted on December 14, 2001
Cost-Effectiveness of a Conservative,
Ischemia-Guided Management Strategy After Non--Q-Wave Myocardial Infarction. Results of a Randomized
Trial
Key words: cost-benefit analysis • myocardial infarction • angiography • tests
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