A management strategy based on exercise echocardiography is more cost-effective than exercise ECG in patients presenting with suspected angina during long term follow up: A randomised study

New onset stable chest pain is a widespread clinical problem. Although Exercise ECG (Ex-ECG) is advocated by European Society of Cardiology guidelines for patients with low to intermediate risk, there have been no randomized studies comparing Ex-ECG with exercise functional imaging that have evaluated long term healthcare costs and clinical outcomes. We present the long term results of the first randomized study of Ex-ECG and exercise stress echocardiography (ESE). Methods: From February 2013 to March 2014, 385 patients with (i) no prior coronary artery disease (CAD),(ii) normal resting ECG and (iii) low-intermediate pretest probability of CAD, were randomized to undergo either Ex-ECG (194 patients) or ESE (191 patients). The mean age was 55±11 years, 68% were male and mean pretest probability of CAD was 34%, with no significant difference be- tween the 2 groups. During a mean of follow up of 3.0 years, the pre-specified, combined endpoint of death, non-fatal myocardial infarction, late revascularization and hospitalization for chest pain occurred in 26 patients in the Ex-ECG arm (3.7%) and 20 patients in the SE arm (3.2%) (hazard ratio, 1.15; 95% confidence interval [CI], 0.39 to 3.43; P=0.38). Resource consumption data were collected on emergency department visits, days in hospital, specialist clinic review, coronary angiography and coronary revascularization procedures. In total, 26 patients in the Ex-ECG arm and 12 patients in the ESE arm underwent invasive angiography (13.4% vs 6.3%, p=0.02) (Fig 1). At 1 year, the mean cost difference between the groups was £81.31. In year 2, the mean cost difference increased by £34.42, and in year 3, the mean cost difference increased further by £19.29. The overall cumulative costs for the entire duration of follow up were £154,382 for Ex-ECG and £120,425 for ESE, giving a unit cost of £796 and £631 respectively (p=0.04). This equated to a greater than 20% reduction in cost with an ESE strategy. Conclusion: In patients with suspected angina, an ESE management strategy is significantly more cost-effective than Ex-ECG during long term follow up, and leads to less invasive angiography. ESE and not Ex-ECG should be the first line test in suspected CAD which has implications on the present guidelines.