Emergency Department Triage Strategies for Acute Chest Pain Using Creatine Kinase–MB and Troponin I Assays: A Cost-Effectiveness Analysis

21 December 1999 | Volume 131 Issue 12 | Pages 909-918

Background: Evaluation of acute chest pain is highly variable.

Objective: To evaluate the cost-effectiveness of strategies using cardiac markers and noninvasive tests for myocardial ischemia.

Design: Cost-effectiveness analysis.

Data Sources: Prospective data from 1066 patients with chest pain and from the published literature.

Target Population: Patients admitted with acute chest pain.

Time Horizon: Lifetime.

Perspective: Societal.

Interventions: Creatine kinase (CK)-MB mass assay alone; CK-MB mass assay followed by cardiac troponin I assay if the CK-MB value is normal; CK-MB mass assay followed by troponin I assay if the CK-MB value is normal and electrocardiography shows ischemic changes; both CK-MB mass and troponin I assays; and troponin I assay alone. These strategies were evaluated alone or in combination with early exercise testing.

Outcome Measures: Lifetime cost, life expectancy (in years), and incremental cost-effectiveness.

Results of Base-Case Analysis: For patients 55 to 64 years of age, measurement of CK-MB mass followed by exercise testing in appropriate patients was the most competitive strategy ($43 000 per year of life saved). Measurement of CK-MB mass followed by troponin I measurement had an incremental cost-effectiveness ratio of $47 400 per year of life saved for patients 65 to 74 years of age; it was also the most cost-effective strategy when early exercise testing could not be performed, CK-MB values were normal, and ischemic changes were seen on electrocardiography.

Results of Sensitivity Analysis: Results were influenced by age, probability of myocardial infarction, and medical costs.

Conclusions: Measurement of CK-MB mass plus early exercise testing is a cost-effective initial strategy for younger patients and those with a low to moderate probability of myocardial infarction. Troponin I measurement can be a cost-effective second test in higher-risk subsets of patients if the CK-MB level is normal and early exercise testing is not an option.

Author and Article Information

From Brigham and Women's Hospital, Harvard Medical School, and Harvard School of Public Health, Boston, Massachusetts.

Grant Support: Dr. Polanczyk is sponsored by a scholarship from CAPES, Brasilia, Brazil.

Requests for Reprints: Thomas H. Lee, MD, Partners Community HealthCare, Inc., Suite 1150, Prudential Tower, Boston, MA 02119; e-mail, thlee{at}partners.org. For reprint orders in quantities exceeding 100, please contact the Reprints Coordinator; phone, 215-351-2657; e-mail, reprints{at}mail.acponline.org.

Current Author Addresses: Dr. Polanczyk: Hospital de Clinicas de Porto Allegre, Rua Ramiro Barcelos 2350/2228, Porto Allegre, Brazil 90000.

Dr. Kuntz: Harvard School of Public Health, 718 Huntington Avenue, Boston, MA 02115.

Drs. Sacks and Johnson: Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115.

Dr. Lee: Partners Community HealthCare, Inc., Prudential Tower, Suite 1150, 800 Boylston Street, Boston, MA 02199-8001.