Using stress testing to guide primary prevention of coronary heart disease among intermediate-risk patients: a cost-effectiveness analysis.

Galper BZ, Moran A, Coxson PG, Pletcher MJ, Heidenreich P, Lazar LD, Rodondi N, Wang YC, Goldman L. Using stress testing to guide primary prevention of coronary heart disease among intermediate-risk patients: a cost-effectiveness analysis. Circulation. 2012 Jan 17; 125(2):260-70.

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Abstract:

BACKGROUND: Noninvasive stress testing might guide the use of aspirin and statins for primary prevention of coronary heart disease, but it is unclear if such a strategy would be cost effective. METHODS AND RESULTS: We compared the status quo, in which the current national use of aspirin and statins was simulated, with 3 other strategies: (1) full implementation of Adult Treatment Panel III guidelines, (2) a treat-all strategy in which all intermediate-risk persons received statins (men and women) and aspirin (men only), and (3) a test-and-treat strategy in which all persons with an intermediate risk of coronary heart disease underwent stress testing and those with a positive test were treated with high-intensity statins (men and women) and aspirin (men only). Healthcare costs, coronary heart disease events, and quality-adjusted life years from 2011 to 2040 were projected. Under a variety of assumptions, the treat-all strategy was the most effective and least expensive strategy. Stress electrocardiography was more effective and less expensive than other test-and-treat strategies, but it was less expensive than treat all only if statin cost exceeded $3.16/pill or if testing increased adherence from < 22% to > 75%. However, stress electrocardiography could be cost effective in persons initially nonadherent to the treat-all strategy if it raised their adherence to 5% and cost saving if it raised their adherence to 13%. CONCLUSIONS: When generic high-potency statins are available, noninvasive cardiac stress testing to target preventive medications is not cost effective unless it substantially improves adherence.