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Should there be systematic screening of coronary heart disease in asymptomatic patients with risk factors alone? A
1Department of Internal Medicine, Hôpital Cantonal, Geneva.
Insights
Screening for asymptomatic coronary heart disease (CHD) appears more effective than primary prevention strategies. This finding, based on decision analysis, suggests prioritizing early detection for at-risk patients.
Area of Science:
- Cardiology
- Preventive Medicine
- Health Economics
Background:
- Coronary heart disease (CHD) poses a significant health risk.
- Primary prevention strategies, like statin use, are established but their comparative effectiveness needs evaluation.
- Asymptomatic hypercholesterolemia is a key target for prevention and early detection studies.
Purpose of the Study:
- To compare the effectiveness of early screening for asymptomatic coronary heart disease (CHD) versus primary prevention.
- To assess the role of diagnostic tests like exercise tests and scintigraphy in CHD detection.
- To evaluate the cost-effectiveness of screening compared to primary prevention.
Main Methods:
- A decision analysis model was employed to compare three strategies: primary prevention with statins, no intervention (control), and early screening for CHD.
- Data from the WOSCOP study on statin effects in asymptomatic hypercholesterolemia were utilized.
- Diagnostic accuracy of exercise tests, 201Tl scintigraphy, and coronary arteriography were incorporated.
Main Results:
- Screening for asymptomatic CHD was found to be superior to primary prevention across a broad range of CHD probability estimates.
- Sensitivity analysis indicated that screening remains favorable unless test sensitivity drastically decreases or primary prevention efficacy significantly increases.
- Increased CHD mortality rates and higher CHD prevalence favored screening.
Conclusions:
- Early detection and treatment of asymptomatic coronary heart disease through screening offer advantages over primary prevention.
- The cost-effectiveness of screening is favorable, supporting its consideration.
- Further validation through prospective controlled studies is recommended to confirm these findings.
Abstract:
The problem of choosing between detection of asymptomatic coronary heart disease (CHD) in patients at risk and primary prevention was assessed in a decision analysis model. Most of the relevant data were derived from the WOSCOP study, which evaluated the effects of statins in asymptomatic hypercholesterolaemic subjects. This study is considered to be a model of primary prevention measurement. Over a 5-year period, 10% of control subjects had events related to CHD, with a 20% mortality rate which was reduced by 33% under statin administration. A decision tree was used to compare these two sets of data (controls and treated patients) with those of a third option in which an exercise test, 201Tl scintigraphy and, in certain cases, coronary arteriography were used to detect and treat CHD at an asymptomatic stage. The test characteristics and outcomes correspond as closely as possible to previously reported data, concerning what can be expected in this particular situation. Over a wide range of CHD probabilities, screening appeared to be better than primary prevention. This result is robust since it was not modified by sensitivity analysis for most of the data. A sharp decrease in the sensitivity of the first two tests and a marked increase in the effectiveness of primary prevention would alter the decision in favour of primary prevention, whereas an increased death rate from CHD and higher CHD probability would favour the utility of screening. As the cost-effectiveness of screening compares favourably with that of primary prevention, it may be useful to assess the validity of this model in a prospective controlled study.