Systematic review, meta-analysis and economic modelling of ...

DOI: 10.3310/hta17010 Health Technology Assessment 2013 Vol. 17 No. 1Appendix 9 Final project descriptionProject titleCost-effectiveness of diagnostic strategies for suspected acute coronary syndrome (ACS).Planned investigationResearch objectives1. To estimate the diagnostic accuracy for myocardial infarction and prognostic accuracy for cardiacevents of biomarkers used to investigate suspected ACS.2. To estimate the cost-effectiveness of biomarker strategies for investigating suspected ACS.3. To estimate the diagnostic accuracy for coronary artery disease (CAD) and prognostic accuracy forcardiac events of multislice CT coronary angiography and exercise ECG in patients with suspected ACS.4. To estimate the cost-effectiveness of multislice CT coronary angiography and exercise ECG forinvestigating patients with troponin-negative suspected ACS.5. To identify the critical areas of uncertainty in the management of suspected ACS, where future primaryresearch would produce the most benefit.Existing researchACS typically occurs when a patient with CAD develops obstruction of their heart arteries. This can lead tomyocardial infarction (MI), heart failure, arrhythmia, cardiac arrest and death. ACS has 6-month mortalityof up to 20% [2] and a fifth of patients are rehospitalised within 6 months of their initial admission [3].ACS usually presents as chest pain and must be differentiated from other common causes of chest pain,such as muscular pain, gastro-oesophageal pain and anxiety. Differentiation is difficult because clinicalassessment is unreliable and the ECG may be normal in the presence of ACS. Patients with suspected ACStherefore constitute a large and varied population, many of whom will not have ACS or CAD, but havenon-cardiac causes for their chest pain. Accurate identification of ACS and CAD are therefore required toguide subsequent intervention.Suspected ACS represents a substantial health-care problem and investigation represents a substantialchallenge. Chest pain is responsible for around 700,000 emergency department attendances in Englandand Wales [4], with the main reason for attendance being suspected ACS. Hospital Episodes Statistics forEngland (2006–7) showed 158,342 emergency admissions with ischaemic heart disease, accounting foralmost 1 million bed-days. In addition, many of the 351,716 emergency admissions classified as ‘signs andsymptoms involving the circulatory or respiratory system’ will have been due to suspicion of ACS.Investigation for suspected ACS has two main elements: (1) diagnosis of MI, and (2) diagnosis ofunderlying CAD. Diagnosis of unstable angina is another consideration but of decreasing importance forreasons outlined below.Diagnosis of MIThe term MI usually refers to NSTEMI in the context of investigating suspected ACS. Although ST-elevationMI is included in the definition of ACS it can usually be identified on the presenting ECG and thus doesnot form part of the typical diagnostic challenge of suspected ACS, although ECG interpretation anddifferentiation from other causes of ST elevation may present separate challenges.© Queen’s Printer and Controller of HMSO 2013. This work was produced by Goodacre et al. under the terms of a commissioning contract issued by the Secretary of Statefor Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journalsprovided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should beaddressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton SciencePark, Southampton SO16 7NS, UK.177