• C A Polanczyk, K M Kuntz, D B Sacks, P A Johnson, and T H Lee.
• Brigham and Women's Hospital, Harvard Medical School, and Harvard School of Public Health, Boston, Massachusetts, USA.
• Ann. Intern. Med. 1999 Dec 21;131(12):909-18.

BackgroundEvaluation of acute chest pain is highly variable.ObjectiveTo evaluate the cost-effectiveness of strategies using cardiac markers and noninvasive tests for myocardial ischemia.DesignCost-effectiveness analysis.Data SourcesProspective data from 1066 patients with chest pain and from the published literature.Target PopulationPatients admitted with acute chest pain.Time HorizonLifetime.PerspectiveSocietal.InterventionsCreatine 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 MeasuresLifetime cost, life expectancy (in years), and incremental cost-effectiveness.Results Of Base Case AnalysisFor patients 55 to 64 years of age, measurement of CK-MB mass followed by exercise testing in appropriate patients was the most competitive strategy ($43000 per year of life saved). Measurement of CK-MB mass followed by troponin I measurement had an incremental cost-effectiveness ratio of $47400 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 AnalysisResults were influenced by age, probability of myocardial infarction, and medical costs.ConclusionsMeasurement 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.

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