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Cost-Efficiency of Myocardial Contrast Echocardiography in Patients Presenting to the Emergency Department With Chest Pain of Suspected Cardiac Origin and a Nondiagnostic Electrocardiogram

      Assessment of patients presenting to the emergency department (ED) with suspected cardiac chest pain and a nondiagnostic electrocardiogram (ECG) is lengthy and costly. It was hypothesized that myocardial contrast echocardiography (MCE) can be cost-efficient in such patients by detecting those with chest pain that is noncardiac in nature. Accordingly, cost-efficiency was evaluated in 957 patients presenting to the ED with suspected cardiac chest pain, but no ST-segment elevation on the ECG, who underwent MCE. Economic outcome calculations were based on costs estimated from national average Medicare charges adjusted by a cost–charge ratio. Based on routine clinical criteria, 641 patients (67%) were admitted to the hospital, whereas 316 (33%) were discharged directly from the ED. The average cost per patient using routine evaluation was $5,000. Patients with normal MCE results (n = 523) had a very low primary event rate (death, acute myocardial infarction) of 0.6% within 24 hours after presentation, making it relatively safe to discharge patients directly from the ED with a normal MCE result. Hence, if MCE had been used for decision making, 523 patients (55%) would have been discharged directly from the ED and 434 (45%) would have been admitted to the hospital. Preventing unnecessary admissions and tests would have saved an average of $900 per patient, in addition to reducing their ED stay. In conclusion, by excluding cardiac causes in patients presenting to the ED with chest pain and a nondiagnostic ECG, MCE can prevent unnecessary admissions and downstream resource utilization, making it a cost-efficient tool in the evaluation of these patients.
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      References

        • Tong K.L.
        • Kaul S.
        • Wang X.Q.
        • Rinkevich D.
        • Kalvaitis S.
        • Belcik T.
        • Lepper W.
        • Foster W.A.
        • Wei K.
        Myocardial contrast echocardiography versus TIMI score in patients presenting to the emergency department with chest pain and a non-diagnostic electrocardiogram.
        J Am Coll Cardiol. 2005; 46: 920-927
        • Rinkevich D.
        • Kaul S.
        • Lepper W.
        • Wang X.Q.
        • Tong K.L.
        • Belcik T.
        • Kalvitis S.
        • Lepper W.
        • Dent J.M.
        • Wei K.
        Regional left ventricular perfusion and function in patients presenting to the emergency department with chest pain and no ST segment elevation.
        Eur Heart J. 2005; 26: 1606-1611
        • Kalvaitis S.
        • Kaul S.
        • Rinkevich D.
        • Tong K.L.
        • Belcik T.
        • Wei K.
        Effect of time delay on the diagnostic and prognostic utility of myocardial contrast echocardiography in patients presenting with suspected cardiac chest pain to the emergency department.
        J Am Soc Echocardiogr. 2006; 19: 1488-1493
        • Dawson D.
        • Rinkevich D.
        • Belcik T.
        • Jayaweera A.R.
        • Rafter P.
        • Kaul S.
        • Wei K.
        Measurement of myocardial blood flow velocity reserve with myocardial contrast echocardiography in patients with suspected coronary artery disease: comparison with quantitative gated 99mTc sestamibi SPECT.
        J Am Soc Echocardiogr. 2003; 16: 1171-1177
      1. TreeAge Pro 2006 User's manual.
        in: TreeAge Software, Williamstown, MA2006: 16-25
        • Villanueva F.S.
        • Sabia P.J.
        • Afrookteh A.
        • Pollock S.G.
        • Hwang L.J.
        • Kaul S.
        Value and limitations of current methods of evaluating patients presenting to the emergency room with cardiac-related symptoms for determining long-term prognosis.
        Am J Cardiol. 1992; 69:: 746-750
        • Antman E.M.
        • Tanasijevic M.J.
        • Thompson B.
        • Schactman M.
        • McCabe C.H.
        • Cannon C.P.
        Cardiac-specific troponin I levels to predict the risk of mortality in patients with acute coronary syndromes.
        N Engl J Med. 1996; 335: 1342-1349
        • Luscher M.S.
        • Thygesen K.
        • Ravkilde J.
        • Heickendorff L.
        • TRIM Study Group
        Applicability of cardiac troponin T and I for early risk stratification in unstable coronary artery disease.
        Circulation. 1997; 96: 2578-2585
        • Lee T.H.
        • Cook E.F.
        • Weisberg M.
        • Sargent R.K.
        • Wilson C.
        • Goldman L.
        Acute chest pain in the emergency room.
        Arch Intern Med. 1985; 145: 65-69
        • McCarthy B.D.
        • Beshansky J.R.
        • D'Agostino R.B.
        • Selker H.P.
        Missed diagnoses of acute myocardial infarction in the emergency department: results from a multicenter study.
        Ann Emerg Med. 1993; 22: 579-582
        • Pope J.H.
        • Ruthazer R.
        • Beshansky J.R.
        • Griffith J.L.
        • Selker H.P.
        The clinical presentation of patients with acute cardiac ischemia in the emergency department: a multicenter controlled clinical trial.
        J Thromb Thrombolysis. 1998; 6: 63-74
        • Lee T.H.
        • Rouan G.W.
        • Weisberg M.C.
        • Brand D.A.
        • Acampora D.
        • Stasiulewicz C.
        • Walshon J.
        • Terranova G.
        • Gottlieb L.
        • Goldstein-Wayne B.
        Clinical characteristics and natural history of patients with acute myocardial infarction sent home from the emergency room.
        Am J Cardiol. 1987; 60: 219-224
        • Bambha K.
        • Kim W.R.
        Cost-effectiveness analysis and incremental cost-effectiveness ratios: uses and pitfalls.
        Eur J Gatroenterol Hepatol. 2004; 16: 519-526
        • Weinstein M.C.
        • Fineberg H.V.
        • Ebstein A.S.
        • Frazier H.S.
        • Heuhauser D.
        • Neutra R.R.
        • McNeil B.S.
        Clinical decision and limited resources.
        in: Clinical decision analysis. Saunders, Philadelphia, PA1998: 228-265
        • Amsterdam E.A.
        • Kirk J.D.
        • Diercks D.B.
        • Lewis W.R.
        • Turnipseed S.
        Immediate exercise testing to evaluate low risk patients presenting to the emergency department with chest pain.
        J Am Coll Cardiol. 2002; 40: 251-256
        • Stein R.A.
        • Chaitman B.R.
        • Balady G.J.
        • Fleg J.L.
        • Limacher M.C.
        • Pina I.L.
        • Williams M.A.
        • Bazzarre T.
        Safety and utility of exercise testing in emergency room chest pain centers.
        Circulation. 2000; 102: 1463-1467
        • Nucifora G.
        • Badano L.P.
        • Sarraf-Zadegan N.
        • Karavidas A.
        • Trocino G.
        • Scaffidi G.
        • Pettinati G.
        • Astarita C.
        • Vysniauskas V.
        • Gregori D.
        • et al.
        Comparison of early dobutamine stress echocardiography and exercise electrocardiographic testing for management of patients presenting to the emergency department with chest pain.
        Am J Cardiol. 2007; 100: 1068-1073