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Ten ways to enhance a stable CAD pathway

Map of Medicine has analysed the evidence on how to manage patients with stable coronary artery disease (CAD) in a way that will reduce costs – while maintaining quality

1) Do not perform further investigations to diagnose CAD, such as coronary angiography, in patients with an estimated likelihood of CAD over 90%.1

If patients have features of typical angina based on clinical assessment and their likelihood of CAD is greater than 90%, further diagnostic investigation is not necessary. Manage as angina.1

2) Offer invasive coronary angiography as first line for patients with estimated CAD risk of 60-90%.1

Health economic modelling by NICE demonstrated that when the likelihood of CAD is 60-90%, the most cost-effective strategy is invasive coronary angiography.1

3Do not use exercise ECG as a first-line investigation in patients with chest pain and no history of CAD.1

Modelling by NICE indicates exercise ECG is only cost-effective first line when the estimated likelihood of a patient having CAD is 5% or less.1 Even in this instance, calcium scoring instead is likely to improve effectiveness at a reasonable cost.1

4) Offer calcium scoring as a first-line test in patients with estimated CAD risk of 10-29%.1

Calcium scoring – a CT scan to check for build-up of calcium in the artery walls – is cost-effective as a first-line test and should be followed by either 64-slice CT coronary angiography alone or with invasive coronary angiography.1

5) Initiate ACE inhibitors with the lowest-cost generic version.2

Some generic ACE inhibitors are less costly than branded versions but equally as effective.2 The volume of prescribing of ACE inhibitors is increasing significantly.2

6) Consider prescribing an ACE inhibitor in all people with stable CAD.3

The EUROPA trial showed that perindopril 8mg once daily in patients with stable CAD resulted in a 20% relative risk reduction in the primary endpoint of cardiovascular death, myocardial infarction or cardiac arrest.3 An economic evaluation by Briggs et al (2006) found the median incremental cost per quality adjusted life year (QALY) gained with perindopril over placebo was £9,700, and concluded that perindopril in patients with stable CAD was cost-effective compared with placebo.3

7) Do not prescribe clopidogrel for longer than 12 months post-stent insertion in people who have undergone percutaneous coronary intervention (PCI).4

A meta-analysis of randomised controlled trials by Bowry et al (2008) found that in patients who have undergone PCI, the combination of aspirin plus clopidogrel reduces the frequency of major coronary events compared with aspirin alone.5 An economic evaluation by Cheng et al (2007) showed clopidogrel to be cost-effective when used for up to 12 months in combination with aspirin in patients undergoing PCI.4 The median incremental cost per QALY gained was £18,888.4

8) Do not initiate therapy with a high-intensity statin for secondary prevention in people with stable CAD.6

Health economic modelling by NICE demonstrated the use of high-intensity statins for secondary prevention in people with CAD resulted in fewer cardiovascular events, but was not cost-effective compared with low-intensity statin therapy.6

9) Consider PCI with bare metal stents as first-line intervention for revascularisation for stable patients with multivessel coronary disease (MVD).7

A Canadian economic evaluation by Wang et al (2006) assessed four revascularisation procedures. The one-year clinical event rate was 9.8% for PCI with bare metal stents (BMS) and for PCI with drug-eluting stents (DES), 9.6% for off-pump coronary artery bypass grafting (CABG), and 12.4% for on-pump CABG.

Total expected costs were C$10,555 (about £6,200 as of January 2006) for BMS, C$13,827 (£6,800 as of January 2006) for DES, C$13,395 (£6,600 as of January 2006) for off-pump CABG, and C$15,103 (£7,400 as of January 2006) for on-pump CABG. The cost-effectiveness analysis concluded that revascularisation using PCI with BMS was the least costly option for a population of stable CAD with MVD.7

10) Do not use DES for patients having revascularisation with PCI.8

A Canadian economic evaluation by Goeree et al (2009) assessed the cost-effectiveness of DES compared with BMS.

The two-year costs were C$3,888 (£2,200 as of January 2009) per patient with DES and C$2,154 (£1,200) with BMS. The incremental cost per avoided revascularisation with DES compared with BMS was C$52,585 (£30,000), while the incremental cost per QALY gained was C$1,569,875 (£900,000).

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The productivity considerations presented in this document are relevant to the UK. They were identified by systematically searching for and appraising productivity evidence from multiple sources, including NICE guidance, health economic databases and Zynx Health (a sister company of Map of Medicine). A productivity message explicitly states interventions that can reduce the cost of care, while maintaining or improving patient outcomes.

Actions that are believed to lead to improved productivity but lack unequivocal clinical or economic evidence are not included. Some productivity considerations are informed by more recent evidence than that included in relevant national guidelines. The document has been peer reviewed by an independent group of experts.

Blocked coronary artery before angioplasty