The Value of Myocardial Perfusion Scintigraphy in the Diagnosis and Management of Angina and Myocardial Infarction: A Probabilistic Economic Analysis

Background and Aim. Coronary heart disease (CHD) is the most common cause of death in the United Kingdom, accounting for more than 120,000 deaths in 2001, among the highest rates in the world. This study reports an economic evaluation of single photon emission computed tomography myocardial perfusion scintigraphy (SPECT)for the diagnosis and management of coronary artery disease (CAD). Methods. Strategies involving SPECT with and without stress electrocardiography (ECG) and coronary angiography (CA) were compared to diagnostic strategies not involving SPECT. The diagnosis decision was modeled with a decision tree model and long-term costs and consequences using a Morkov model. Data to populate the models were obtained from a series of systematic reviews. Unlike earlier evaluations, a probabilistic analysis was included to assess the statistical imprecision of the results. The results are presented in terms of incremental cost per quality-adjusted life year (QALY). Results. At prevalence levels of CAD of 10.5%, SPECT-based strategies are cost-effective; ECG-CA is highly unlikely to be optimal. At a ceiling ratio of 20,000 pound per QALY, SPECT-CA has a 90% likelihood of being optimal. Beyond this threshold, this strategy becomes less likely to be cost-effective. At more than 75,000 pound per QALY, coronary angiography is most likely to be optimal. For higher levels of prevalence (around 50%) and more than a 10,000 pound per QALY threshold, coronary angiography is the optimal decision. Conclusions. SPECT-based strategies are likely to be cost-effective when risk of CAD is modest (10.5%). Sensitivity analyses show these strategies dominated non-SPECT-based strategies for risk of CAD up to 4%. At higher levels of prevalence, invasive strategies may become worthwhile. Finally, sensitivity analyses show stress echocardiography as a potentially cost-effective option, and further research to assess the relative cost-effectiveness of echocardiography should also be performed.