The decision concerning coronary angiography in patients with chest pain. A cost-effectiveness analysis

We examined the decision whether to perform coronary angiography (followed by bypass surgery if appropriate findings are present) in middle-aged men who have chest pain and have undergone exercise tolerance testing (ETT). We developed a model of this decision that combines data from a variety of sources and selects the optimal strategy based on health outcome and, if desired, monetary cost. The analysis supports the following conclusions: for patients with nonspecific chest pain or atypical angina, the ETT provides useful information concerning the decision; furthermore, the number of millimeters of ST-segment depression above which angiography should be performed depends on coronary risk factors and pain severity. A normal ETT is insufficient evidence to exclude coronary angiography for patients with typical angina, provided that one is willing to expand resources for health benefits at levels comparable to those for other accepted medical practices. If monetary considerations are excluded, the preceding statement concerning ETT and angiography also holds for patients with atypical angina and for those with nonspecific pain and advanced risk factors. These last two conclusions suggest that ETT is not useful in guiding management decisions concerning coronary angiography in patients at high enough risk of coronary artery disease on the basis of symptoms and risk profile.