Cost savings from prioritization of non-invasive modalities within CAD diagnostic protocols: a systematic review.

Aims: While the clinical benefits of non-invasive modalities to diagnose coronary artery disease (CAD) are well recognized, the economic implications of their use over invasive options remain unclear. This review aims to understand the health economic consequences of using non-invasive versus invasive modalities in symptomatic patients with low-to-intermediate pre-test probability (PTP) of CAD, and to explore whether economic and humanistic data can inform future investment decisions around non-invasive and invasive diagnostic modalities.

Materials And Methods: We performed a systematic review of MEDLINE and Embase, MEDLINE In-process, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials. Studies from January 1992 to January 2023 were included, if they were based in the UK, France, Germany, Italy, Japan, China, and/or the USA (published in any language). Risk of bias was assessed using the Drummond checklist.We evaluated invasive techniques, including invasive catheterization angiography (ICA) and ICA with fractional flow reserve (ICA-FFR), as well as non-invasive modalities, including coronary computerized tomography angiography (CCTA), CCTA-FFR, cardiovascular magnetic resonance (CMR), stress electrocardiogram, myocardial perfusion scintigraphy-single photon emission computed tomography, positron emission tomography, and stress echocardiography.

Results: Thirty-nine unique records reported relevant outcomes and were fully extracted. In patients with a low-to-intermediate PTP of CAD, most of the comparisons of non-invasive modalities followed or not by confirmatory ICA imaging, versus ICA demonstrated cost savings. The use of non-invasive modalities, followed or not followed by confirmatory ICA, was reported to reduce the number of revascularizations and length of hospital stays, versus ICA alone.

Conclusion: This study suggests that investment in CAD diagnosis should prioritize the use of CCTA and CMR imaging over ICA and other non-invasive modalities.