Decision Analytic Model for Evaluation of Suspected Coronary Disease with Stress Testing and Coronary CT Angiography

Halpern, Ethan J.; Fischman, David; Savage, Michael P.; Koka, Anish R.; DeCaro, Matthew; Levin, David C.

doi:10.1016/j.acra.2009.12.015

« Previous Next »Academic Radiology
Volume 17, Issue 5 , Pages 577-586, May 2010

Decision Analytic Model for Evaluation of Suspected Coronary Disease with Stress Testing and Coronary CT Angiography

Ethan J. Halpern, MD
- Department of Radiology, Thomas Jefferson University, 132 S 10th Street, Philadelphia, PA 19107-5244
- Address correspondence to: E.J.H.
David Fischman, MD
- Division of Cardiology, Department of Medicine, Thomas Jefferson University, 132 S 10th Street, Philadelphia, PA 19107-5244
Michael P. Savage, MD
- Division of Cardiology, Department of Medicine, Thomas Jefferson University, 132 S 10th Street, Philadelphia, PA 19107-5244
Anish R. Koka, MD
- Division of Cardiology, Department of Medicine, Thomas Jefferson University, 132 S 10th Street, Philadelphia, PA 19107-5244
Matthew DeCaro, MD
- Division of Cardiology, Department of Medicine, Thomas Jefferson University, 132 S 10th Street, Philadelphia, PA 19107-5244
David C. Levin, MD
- Department of Radiology, Thomas Jefferson University, 132 S 10th Street, Philadelphia, PA 19107-5244

Received 9 November 2009; accepted 15 December 2009. published online 22 February 2010.

Rationale and Objectives

The aim of this study was to apply a decision analytic model for the evaluation of coronary artery disease (CAD) to define the optimal utilization of coronary computed tomographic angiography (cCTA) and stress testing.

Materials and Methods

The model tested in this study assumes that CAD is evaluated with a stress test and/or cCTA and that a patient with positive evaluation results undergoes cardiac catheterization. On the basis of values of sensitivity, specificity, and radiation dose from the published literature and test costs from the Medicare fee schedule, a decision tree model was constructed as a function of disease prevalence.

Results

The false-negative rate is lowest when cCTA is used as an isolated test. The false-positive rate is minimized when cCTA is used in combination with stress echocardiography. Effective radiation is minimized by use of stress electrocardiography or stress echocardiography alone or prior to cCTA. When the pretest probability of CAD is low, a strategy that uses stress echocardiography followed by cCTA minimizes the false-positive rate and effective radiation exposure, with relatively low imaging costs and with a false-negative rate only slightly higher than a strategy including stress myocardial scintigraphy. As the pretest probability of CAD increases above 20%, the false-negative rate of stress echocardiography followed by cCTA increases by >5% relative to cCTA alone.

Conclusion

Effective radiation dose and imaging costs for the workup of CAD may be minimized by an appropriate combination of stress testing and cCTA. A strategy that uses stress echocardiography followed by cCTA is most appropriate for the evaluation of low-risk patients with CAD with a pretest probability < 20%, while cCTA alone may be more appropriate in intermediate-risk patients.

Key Words: CT angiography, coronary artery disease, radiation exposure, imaging cost, cost-effectiveness