Cost-effective management of patients following myocardial infarction: the impact of ischemia on alternative approaches.

Following uncomplicated myocardial infarction patients are at varying risk for cardiovascular morbidity and mortality. In order to identify and treat high risk patients, various management approaches can be employed. We performed a decision analysis to examine the cost-effectiveness of seven alternative strategies under the assumption that prognosis is affected by both the location of anatomic obstruction and the degree of myocardial ischemia. Strategies included combinations of angiography and two theoretical diagnostic tests capable of detecting ischemia with different degrees of accuracy. The strategy associated with the lowest overall six month mortality initiated testing with the diagnostic test most sensitive for ischemia, slightly better than proceeding initially to angiography. Initial use of a test sensitive for ischemia was also considerably more cost-effective than proceeding directly to angiography. Future analyses evaluating the role of diagnostic tests in coronary artery disease should incorporate the dimension of ischemia.