Coronary computed tomography versus exercise testing in patients with stable chest pain: comparative effectiveness and costs.

BACKGROUND: To determine the comparative effectiveness and costs of a CT-strategy and a stress-electrocardiography-based strategy (standard-of-care; SOC-strategy) for diagnosing coronary artery disease (CAD). METHODS: A decision analysis was performed based on a well-documented prospective cohort of 471 outpatients with stable chest pain with follow-up combined with best-available evidence from the literature. Outcomes were correct classification of patients as CAD- (no obstructive CAD), CAD+ (obstructive CAD without revascularization) and indication for Revascularization (using a combination reference standard), diagnostic costs, lifetime health care costs, and quality-adjusted life years (QALY). Parameter uncertainty was analyzed using probabilistic sensitivity analysis. RESULTS: For men (and women), diagnostic cost savings were €245 (€252) for the CT-strategy as compared to the SOC-strategy. The CT-strategy classified 82% (88%) of simulated men (women) in the appropriate disease category, whereas 83% (85%) were correctly classified by the SOC-strategy. The long-term cost-effectiveness analysis showed that the SOC-strategy was dominated by the CT-strategy, which was less expensive (-€229 in men, -€444 in women) and more effective (+0.002 QALY in men, +0.005 in women). The CT-strategy was cost-saving (-€231) but also less effective compared to SOC (-0.003 QALY) in men with a pre-test probability of ≥ 70%. The CT-strategy was cost-effective in 100% of simulations, except for men with a pre-test probability ≥ 70% in which case it was 59%. CONCLUSIONS: The results suggest that a CT-based strategy is less expensive and equally effective compared to SOC in all women and in men with a pre-test probability <70%.

Clinically suspected constrictive pericarditis: MR imaging assessment of ventricular septal motion and configuration in patients and healthy subjects.

PURPOSE: To assess ventricular septal motion and quantify the septal configuration in patients clinically suspected of having constrictive pericarditis (CP), and to compare these patients with healthy subjects and with patients who have other diastolic heart abnormalities such as restrictive cardiomyopathy (RCM). MATERIALS AND METHODS: In 41 patients clinically suspected of having CP and 12 healthy subjects, magnetic resonance (MR) imaging yielded information about cardiac morphology and function. On short-axis cine MR images, septal motion was assessed, and the septal and left ventricular free wall (LVFW) radii of curvature were quantified and normalized to end systole. Abnormal diastolic septal motion was expressed in terms of the largest difference in normalized radius between the septum and the LVFW. Analysis of variance was used to identify significant differences in septal shape among subject groups. RESULTS: Left-sided septal flattening was identified in 17 of the 21 patients with surgically proven CP, in none of the 20 patients without CP, and in none of the healthy subjects. CP without septal flattening was present on the left side (n = 1), on the right side (n = 1), and at the atrioventricular grooves (n = 2). Abnormal septal motion yielded a sensitivity of 81% (17 of 21 patients), specificity of 100% (20 of 20 patients), accuracy of 90% (37 of 41 patients), positive predictive value of 100% (17 of 17 patients), and negative predictive value of 83% (20 of 24 patients) in the detection of CP. The maximal difference in normalized radius of curvature between the septum and the LVFW in the patients with CP was significantly different from that in the patients without CP (P <.001) and that in the healthy subjects (P <.001). CONCLUSION: Abnormal diastolic septal motion is a frequent phenomenon of CP. If present in patients suspected of having CP, this finding is helpful in distinguishing CP from RCM.