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Could Computed Tomography Coronary Angiography Replace Invasive Coronary Angiography as a First-Line Diagnostic
Taylor Strube1, Kristina Lambrakis2, Kate George1
1South Australian Department of Health, Adelaide, SA, Australia.
Insights
Computed tomography coronary angiography (CTCA) is a cost-effective initial strategy for patients with elevated cardiac troponin levels, up to a 60% probability of needing revascularization. This non-invasive approach offers a safer alternative to invasive coronary angiography in select acute coronary syndrome cases.
Area of Science:
- Cardiology
- Medical Imaging
- Health Economics
Background:
- High-sensitivity cardiac troponin (hs-cTn) assays identify more patients with modestly elevated troponin.
- Coronary angiography rates increased post-hs-cTn implementation, without proportional revascularization increases.
- Computed tomography coronary angiography (CTCA) offers a non-invasive alternative for evaluating these patients.
Purpose of the Study:
- To determine the cost-effectiveness of CTCA versus invasive coronary angiography (ICA) as an initial strategy.
- To define the pre-test probability threshold for coronary revascularization where CTCA is safe and cost-effective.
- To evaluate CTCA as a risk-appropriate initial investigation for suspected acute coronary syndrome with low to moderate hs-cTn increases.
Main Methods:
- A decision-analytic model was used for cost-benefit evaluation.
- The primary outcome was the incremental cost-effectiveness ratio (ICER) of CTCA vs. ICA.
- Secondary outcomes included costs, patient outcomes, and quality-adjusted life years for hs-cTnT levels of 5–100 ng/L.
Main Results:
- The median base case ICER for CTCA was $17,163 AUD, with significant variability.
- CTCA remained cost-effective up to a ~60% pre-test probability of requiring revascularization.
- Beyond 60% probability, CTCA was associated with higher costs and poorer outcomes compared to ICA.
Conclusions:
- CTCA may be a cost-effective first-line investigation for patients with moderate hs-cTnT elevations.
- This cost-effectiveness holds up to a 60% pre-test probability for coronary revascularization.
- Prospective studies are needed to confirm optimal cost-effectiveness circumstances, incorporating revascularization probability estimates.
Background:
The implementation of high-sensitivity cardiac troponin (hs-cTn) assays into clinical practice has resulted in the identification of a novel cohort of patients with modestly increased troponin concentrations. Subsequent increases in rates of coronary angiography have been observed, without significant increases in rates of coronary revascularisation. Computed tomography coronary angiography (CTCA) is a non-invasive investigation that offers the opportunity to decouple investigation from the impetus to revascularise, and may provide an alternative, more risk-appropriate initial investigative strategy for the cohort with low to moderate hs-cTn increases. This analysis seeks to define the threshold of pre-test probability of coronary revascularisation in patients with suspected acute coronary syndrome at which a strategy of initial CTCA is safe and a more cost-effective approach than standard invasive coronary angiography (ICA).
Methods:
A cost-benefit evaluation was conducted using a decision-analytic model. The primary outcome measure was the incremental cost-effectiveness ratio (ICER) of CTCA in comparison with ICA as an initial diagnostic investigation for patients with hs-cTnT levels between 5 and 100 ng/L. Secondary outcome measures of costs, patient outcomes, and quality-adjusted life years were analysed.
Results:
Median base case ICER over 1,000 trials was $17,163 AUD but demonstrated large variability. Sensitivity analysis demonstrated that CTCA was cost-effective until the probability of requiring revascularisation was ∼60%, beyond which point CTCA was associated with higher costs and poorer outcomes than ICA.
Conclusions:
Computed tomography coronary angiography may be a cost-effective first-line investigation for patients with moderate hs-cTnT rises until/up to a 60% pre-test probability for receiving coronary revascularisation. To objectively assess the optimal circumstances of cost-effectiveness, prospective evaluation incorporating the estimated probability of revascularisation will be required.
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