Paramjit Jeetley1, Leah Burden, Boyka Stoykova, Roxy Senior. 1. Department of Cardiovascular Medicine, Northwick Park Hospital and Institute for Medical Research, and Health Economics Research Group, Brunel University, Middlesex, UK.
Abstract
AIMS: Patients attending hospital with suspected acute coronary syndrome (ACS), non-diagnostic electrocardiogram (ECG), and negative troponin present a diagnostic dilemma for admitting physicians. We sought to determine the clinical and economic impact of stress echocardiography (SEcho) when compared with exercise ECG (ExECG) in the assessment of these patients. METHODS AND RESULTS: Following pre-test assessment by (Thrombolysis in Myocardial Infarction) TIMI score, patients were randomized to ExECG (n=218) or SEcho (n=215). Subsequently, low-risk patients were discharged; those considered high risk were referred for coronary angiography. Patients were followed-up for cardiac events and a cost-analysis performed. SEcho was superior to ExECG in stratifying patients as low risk (77 vs. 33%, respectively, P<0.0001) with no difference in cardiac event rate (5 vs. 3%, respectively). SEcho classified fewer patients as intermediate risk (3 vs. 39%, respectively, P<0.0001) and fewer patients required further tests when compared with ExECG (3 vs. 47%, respectively, P<0.0001). Costs for detection of coronary artery disease were significantly less in patients undergoing SEcho (pound366.63 vs. pound515.48, P=0.004). CONCLUSION: SEcho is superior to ExECG in the risk stratification of patients with suspected ACS but negative troponin. SEcho resulted in less diagnostic uncertainty, fewer referrals for further investigation, and hence, a significant cost benefit over ExECG.
RCT Entities:
AIMS: Patients attending hospital with suspected acute coronary syndrome (ACS), non-diagnostic electrocardiogram (ECG), and negative troponin present a diagnostic dilemma for admitting physicians. We sought to determine the clinical and economic impact of stress echocardiography (SEcho) when compared with exercise ECG (ExECG) in the assessment of these patients. METHODS AND RESULTS: Following pre-test assessment by (Thrombolysis in Myocardial Infarction) TIMI score, patients were randomized to ExECG (n=218) or SEcho (n=215). Subsequently, low-risk patients were discharged; those considered high risk were referred for coronary angiography. Patients were followed-up for cardiac events and a cost-analysis performed. SEcho was superior to ExECG in stratifying patients as low risk (77 vs. 33%, respectively, P<0.0001) with no difference in cardiac event rate (5 vs. 3%, respectively). SEcho classified fewer patients as intermediate risk (3 vs. 39%, respectively, P<0.0001) and fewer patients required further tests when compared with ExECG (3 vs. 47%, respectively, P<0.0001). Costs for detection of coronary artery disease were significantly less in patients undergoing SEcho (pound366.63 vs. pound515.48, P=0.004). CONCLUSION: SEcho is superior to ExECG in the risk stratification of patients with suspected ACS but negative troponin. SEcho resulted in less diagnostic uncertainty, fewer referrals for further investigation, and hence, a significant cost benefit over ExECG.