Contrast-Enhanced Stress Echocardiography and Myocardial Perfusion Imaging in Patients Hospitalized With Chest Pain: A Randomized Study.

Ultrasound contrast-enhanced stress echocardiography improves endocardial visualization, but diagnostic test rates versus stress myocardial perfusion imaging (MPI) have not been studied. A prospective randomized trial was performed between April 2012 and October 2014 at a single-center, safety net hospital. Hospitalized patients referred for noninvasive stress imaging were randomized 1:1 to stress echocardiography or stress MPI. The primary outcome was diagnostic test rate defined as interpretable images and achievement of >85% of age-predicted maximal heart rate (for dobutamine and exercise). Rates were assessed among those completing testing and then based solely on image interpretability. Charges and length of stay were secondary outcomes. A total of 240 patients were randomized, and 229 completed testing. Diagnostic test rates were similar for stress echocardiography versus MPI {89.4% [95% confidence interval (CI), 82.2-94.4] vs. 94.8% [95% CI, 89.1-98.1], P = 0.13} and did not differ with multivariable adjustment. Modalities requiring a diagnostic heart rate criteria were more frequently ordered with stress echocardiography (100% vs. 26%; P < 0.001). Therefore, an imaging-based analysis without the 12 individuals who failed to achieve target heart rate (n = 217) was evaluated with diagnostic test rates of 100% versus 94.8% (95% CI, 89.1%-98.1%; P = 0.03) for stress echocardiography and MPI, respectively. Median length of stay did not differ. Median (interquartile range) test-related charges were lower with stress echocardiography: $2,424 ($2400-$2508) versus $3619 ($3584-$3728), P < 0.0001. Overall, tests were positive for ischemia in 8% of patients. In conclusion, contrast-enhanced stress echocardiography provides comparable diagnostic test rates to MPI with lower associated charges.

Cost-effectiveness of a management strategy based on exercise echocardiography versus exercise electrocardiography in patients presenting with suspected angina during long term follow up: A randomized study.

INTRODUCTION: Exercise ECG (Ex-ECG) is advocated by guidelines for patients with low - intermediate probability of coronary artery disease (CAD). However, there are no randomized studies comparing Ex-ECG with exercise stress echocardiography (ESE) evaluating long term cost-effectiveness of each management strategy. METHODS: Accordingly, 385 patients with no prior CAD and low-intermediate probability of CAD (mean pre-test probability 34%), were randomized to undergo either Ex-ECG (194 patients) or ESE (191 patients). The primary endpoint was clinical effectiveness defined as the positive predictive value (PPV) for the detection of CAD of each test. Cost-effectiveness was derived using the cumulative costs incurred by each diagnostic strategy during a mean of follow up of 3.0 years. RESULTS: The PPV of ESE and Ex-ECG were 100% and 64% (p = 0.04) respectively for the detection of CAD. There were fewer clinic (31 vs 59, p < 0.01) and emergency visits (14 vs 30, p = 0.01) and lower number of hospital bed days (8 vs 29, p < 0.01) in the ESE arm, with fewer patients undergoing coronary angiography (13.4% vs 6.3%, p = 0.02). The overall cumulative mean costs per patient were £796 for Ex-ECG and £631 for ESE respectively (p = 0.04) equating to a >20% reduction in cost with an ESE strategy with no difference in the combined end-point of death, myocardial infarction, unplanned revascularization and hospitalization for chest pain between ESE and Ex-ECG (3.2% vs 3.7%, p = 0.38). CONCLUSION: In patients with low to intermediate pretest probability of CAD and suspected angina, an ESE management strategy is cost-effective when compared with Ex-ECG during long term follow up.

Relative clinical and economic impact of exercise echocardiography vs. exercise electrocardiography, as first line investigation in patients without known coronary artery disease and new stable angina: a randomized prospective study.

AIMS: Exercise electrocardiography (ExECG) is widely used in suspected stable angina (SA) as the initial test for the evaluation of coronary artery disease (CAD). We hypothesized that exercise stress echo (ESE) would be efficacious with cost advantage over ExECG when utilized as the initial test. METHODS AND RESULTS: Consecutive patients with suspected SA, without known CAD were randomized into ExECG or ESE. Patients with positive tests were offered coronary angiography (CA) and with inconclusive tests were referred for further investigations. All patients were followed-up for cardiac events (death, myocardial infarction, and unplanned revascularization). Cost to diagnosis of CAD was calculated by adding the cost of all investigations, up to and including CA. In the 194 and 191 patients in the ExECG vs. ESE groups, respectively, pre-test probability of CAD was similar (34 ± 23 vs. 35 ± 25%, P = 0.6). Results of ExECG were: 108 (55.7%) negative, 14 (7.2%) positive, 72 (37.1%) inconclusive and of ESE were 181 (94.8%) negative, 9 (4.7%) positive, 1 (0.5%) inconclusive, respectively. Patients with obstructive CAD following positive ESE vs. Ex ECG were 9/9 vs. 9/14, respectively (P = 0.04). Cost to diagnosis of CAD was £266 for ESE vs. £327 for ExECG (P = 0.005). Over a mean follow-up period of 21 ± 5 months, event rates were similar between the two groups. CONCLUSION: In this first randomized study, ESE was more efficacious and demonstrated superior cost-saving, compared with ExECG when used as the initial investigation for the evaluation of CAD in patients with new-onset suspected SA without known CAD.

Economic Outcomes With Anatomical Versus Functional Diagnostic Testing for Coronary Artery Disease.

BACKGROUND: PROMISE (PROspective Multicenter Imaging Study for Evaluation of Chest Pain) found that initial use of at least 64-slice multidetector computed tomography angiography (CTA) versus functional diagnostic testing strategies did not improve clinical outcomes in stable symptomatic patients with suspected coronary artery disease (CAD) requiring noninvasive testing. OBJECTIVE: To conduct an economic analysis for PROMISE (a major secondary aim of the study). DESIGN: Prospective economic study from the U.S. perspective. Comparisons were made according to the intention-to-treat principle, and CIs were calculated using bootstrap methods. (ClinicalTrials.gov: NCT01174550). SETTING: 190 U.S. centers. PATIENTS: 9649 U.S. patients enrolled in PROMISE between July 2010 and September 2013. Median follow-up was 25 months. MEASUREMENTS: Technical costs of the initial (outpatient) testing strategy were estimated from Premier Research Database data. Hospital-based costs were estimated using hospital bills and Medicare cost-charge ratios. Physician fees were taken from the Medicare Physician Fee Schedule. Costs were expressed in 2014 U.S. dollars, discounted at 3% annually, and estimated out to 3 years using inverse probability weighting methods. RESULTS: The mean initial testing costs were $174 for exercise electrocardiography; $404 for CTA; $501 to $514 for pharmacologic and exercise stress echocardiography, respectively; and $946 to $1132 for exercise and pharmacologic stress nuclear testing, respectively. Mean costs at 90 days were $2494 for the CTA strategy versus $2240 for the functional strategy (mean difference, $254 [95% CI, -$634 to $906]). The difference was associated with more revascularizations and catheterizations (4.25 per 100 patients) with CTA use. After 90 days, the mean cost difference between the groups out to 3 years remained small. LIMITATION: Cost weights for test strategies were obtained from sources outside PROMISE. CONCLUSION: Computed tomography angiography and functional diagnostic testing strategies in patients with suspected CAD have similar costs through 3 years of follow-up. PRIMARY FUNDING SOURCE: National Heart, Lung, and Blood Institute.

Long-term Cost-Effectiveness of Diagnostic Tests for Assessing Stable Chest Pain: Modeled Analysis of Anatomical and Functional Strategies.

Several tests exist for diagnosing coronary artery disease, with varying accuracy and cost. We sought to provide cost-effectiveness information to aid physicians and decision-makers in selecting the most appropriate testing strategy. We used the state-transitions (Markov) model from the Brazilian public health system perspective with a lifetime horizon. Diagnostic strategies were based on exercise electrocardiography (Ex-ECG), stress echocardiography (ECHO), single-photon emission computed tomography (SPECT), computed tomography coronary angiography (CTA), or stress cardiac magnetic resonance imaging (C-MRI) as the initial test. Systematic review provided input data for test accuracy and long-term prognosis. Cost data were derived from the Brazilian public health system. Diagnostic test strategy had a small but measurable impact in quality-adjusted life-years gained. Switching from Ex-ECG to CTA-based strategies improved outcomes at an incremental cost-effectiveness ratio of 3100 international dollars per quality-adjusted life-year. ECHO-based strategies resulted in cost and effectiveness almost identical to CTA, and SPECT-based strategies were dominated because of their much higher cost. Strategies based on stress C-MRI were most effective, but the incremental cost-effectiveness ratio vs CTA was higher than the proposed willingness-to-pay threshold. Invasive strategies were dominant in the high pretest probability setting. Sensitivity analysis showed that results were sensitive to costs of CTA, ECHO, and C-MRI. Coronary CT is cost-effective for the diagnosis of coronary artery disease and should be included in the Brazilian public health system. Stress ECHO has a similar performance and is an acceptable alternative for most patients, but invasive strategies should be reserved for patients at high risk.

Nuclear Myocardial Perfusion Imaging Versus Stress Echocardiography in the Preoperative Evaluation of Patients for Kidney Transplantation.

UNLABELLED: The goal of this study was to evaluate the diagnostic accuracy, cost-effectiveness, and appropriate use of SPECT myocardial perfusion imaging (SMPI) versus stress echocardiography in the preoperative evaluation of patients for kidney transplantation. METHODS: A single-institution, retrospective study was performed. SMPI was performed with regadenoson and stress echocardiography predominantly with dobutamine. Findings on subsequent coronary angiography were correlated. A cost analysis for SMPI versus stress echocardiography was modeled using reimbursements from the Center for Medicare Services. RESULTS: One hundred thirteen patients underwent imaging (53 SMPI and 60 stress echocardiography). One hundred percent of SMPI studies were diagnostic, compared with only 80% (48/60) in the stress echocardiography group, and this result was statistically significant (χ(2) = 7.96, P < 0.01). The most common reason for a nondiagnostic test was not reaching the target heart rate. In the SMPI group, 15% (8/53) of patients had ischemia on imaging and all underwent subsequent coronary angiography, which confirmed obstructive coronary lesions. One patient with a negative SMPI result underwent a subsequent angiogram that was negative. In the stress echocardiography group, 5% (3/60) of patients had ischemia on imaging and 2 underwent subsequent angiography, which was negative. Three of 12 patients with nondiagnostic examinations underwent further testing. One patient underwent a follow-up positive SMPI scan but no subsequent coronary angiography. The other 2 patients underwent coronary angiography, which was negative. Of the 45 negative stress echocardiography patients, 6 (13%) underwent angiography, with a positive result for obstructive coronary artery disease in 3 of 6. For the modeling of cost analysis, rates of $1,173 and $1,521 (Center for Medicare Services) were used for SMPI and stress echocardiography, respectively. The model assumed that all nondiagnostic imaging would be referred for further stress testing (i.e., nondiagnostic stress echocardiography would be referred for SMPI). This model estimated that initial noninvasive testing with stress echocardiography versus SMPI resulted in a 50% greater cost. CONCLUSION: For the preoperative evaluation of kidney transplantation, SMPI is more often diagnostic than stress echocardiography. A cost model estimates that initial noninvasive diagnostic testing with stress echocardiography would result in an approximately 50% greater cost than SMPI. Our data also suggest that SMPI has greater diagnostic accuracy than stress echocardiography. Therefore, this single-institution experience supports SMPI as the more appropriate test.

Comparison of clinical efficacy and cost of a cardiac imaging strategy versus a traditional exercise test strategy for the investigation of patients with suspected stable coronary artery disease.

We evaluated the clinical efficacy and cost of a cardiac imaging strategy versus a traditional exercise tolerance test (ETT) strategy for the investigation of suspected stable coronary artery disease (CAD). We retrospectively collected data of consecutive patients seen in rapid access chest pain clinics at 2 UK hospitals for a period of 12 months. Hospital A investigated patients by performing ETT. Hospital B investigated patients using cardiac imaging test; 483 patients from hospital A and 295 from hospital B were included. In hospital A, 209 patients (43.3%) had contraindication to ETT. Of those who had ETT, 151 (55.1%) had negative ETT, 68 (24.8%) had equivocal ETT, and 55 (20.1%) had positive ETT, of which 53 (96.4%) had invasive coronary angiography (ICA), and of these 23 (43.4%) had obstructive CAD. In hospital B, 26 patients (8.8%) with low pretest probability had calcium score and 3 (11.5%) were positive leading to computed tomography coronary angiography; 98 patients (33.2%) with intermediate pretest probability had computed tomography coronary angiography and 5 (5.1%) were positive; 77 patients (26.1%) had stress echocardiogram and 6 (7.8%) were positive; and 57 patients (19.3%) had myocardial perfusion scintigraphy and 11 (19.3%) were positive. Hospital A performed 127 ICA (26.3% of population) and 52 (40.9%) had obstructive CAD. Hospital B performed 63 ICA (21.4% of population) and 32 (50.8%) had obstructive CAD. The average cost per patient in hospital A was £566.6 ± 490.0 ($875 ± 758) and in hospital B was £487.9 ± 469.6 ($750 ± 725) (p <0.001). In conclusion, our results suggest that a cardiac imaging pathway leads to fewer ICA and a higher yield of obstructive CAD at lower cost per patient.

PROspective Multicenter Imaging Study for Evaluation of chest pain: rationale and design of the PROMISE trial.

BACKGROUND: Suspected coronary artery disease (CAD) is one of the most common, potentially life-threatening diagnostic problems clinicians encounter. However, no large outcome-based randomized trials have been performed to guide the selection of diagnostic strategies for these patients. METHODS: The PROMISE study is a prospective, randomized trial comparing the effectiveness of 2 initial diagnostic strategies in patients with symptoms suspicious for CAD. Patients are randomized to either (1) functional testing (exercise electrocardiogram, stress nuclear imaging, or stress echocardiogram) or (2) anatomical testing with ≥64-slice multidetector coronary computed tomographic angiography. Tests are interpreted locally in real time by subspecialty certified physicians, and all subsequent care decisions are made by the clinical care team. Sites are provided results of central core laboratory quality and completeness assessment. All subjects are followed up for ≥1 year. The primary end point is the time to occurrence of the composite of death, myocardial infarction, major procedural complications (stroke, major bleeding, anaphylaxis, and renal failure), or hospitalization for unstable angina. RESULTS: More than 10,000 symptomatic subjects were randomized in 3.2 years at 193 US and Canadian cardiology, radiology, primary care, urgent care, and anesthesiology sites. CONCLUSION: Multispecialty community practice enrollment into a large pragmatic trial of diagnostic testing strategies is both feasible and efficient. The PROMISE trial will compare the clinical effectiveness of an initial strategy of functional testing against an initial strategy of anatomical testing in symptomatic patients with suspected CAD. Quality of life, resource use, cost-effectiveness, and radiation exposure will be assessed.

Cost-effectiveness of initial stress cardiovascular MR, stress SPECT or stress echocardiography as a gate-keeper test, compared with upfront invasive coronary angiography in the investigation and management of patients with stable chest pain: mid-term outcomes from the CECaT randomised controlled trial.

OBJECTIVES: To compare outcomes and cost-effectiveness of various initial imaging strategies in the management of stable chest pain in a long-term prospective randomised trial. SETTING: Regional cardiothoracic referral centre in the east of England. PARTICIPANTS: 898 patients (69% man) entered the study with 869 alive at 2 years of follow-up. Patients were included if they presented for assessment of stable chest pain with a positive exercise test and no prior history of ischaemic heart disease. Exclusion criteria were recent infarction, unstable symptoms or any contraindication to stress MRI. PRIMARY OUTCOME MEASURES: The primary outcomes of this follow-up study were survival up to a minimum of 2 years post-treatment, quality-adjusted survival and cost-utility of each strategy. RESULTS: 898 patients were randomised. Compared with angiography, mortality was marginally higher in the groups randomised to cardiac MR (HR 2.6, 95% CI 1.1 to 6.2), but similar in the single photon emission CT-methoxyisobutylisonitrile (SPECT-MIBI; HR 1.0, 95% CI 0.4 to 2.9) and ECHO groups (HR 1.6, 95% CI 0.6 to 4.0). Although SPECT-MIBI was marginally superior to other non-invasive tests there were no other significant differences between the groups in mortality, quality-adjusted survival or costs. CONCLUSIONS: Non-invasive cardiac imaging can be used safely as the initial diagnostic test to diagnose coronary artery disease without adverse effects on patient outcomes or increased costs, relative to angiography. These results should be interpreted in the context of recent advances in imaging technology. TRIAL REGISTRATION: ISRCTN 47108462, UKCRN 3696.

Cost-effectiveness analysis of coronary artery disease screening in HIV-infected men.

BACKGROUND: HIV-infected patients are at increased risk of coronary artery disease (CAD). We evaluated the cost-effectiveness of cardiac screening for HIV-positive men at intermediate or greater CAD risk. DESIGN: We developed a lifetime microsimulation model of CAD incidence and progression in HIV-infected men. METHODS: Input parameters were derived from two HIV cohort studies and the literature. We compared no CAD screening with stress testing and coronary computed tomography angiography (CCTA)-based strategies. Patients with test results indicating 3-vessel/left main CAD underwent invasive coronary angiography (ICA) and received coronary artery bypass graft surgery. In the stress testing + medication and CCTA + medication strategies, patients with 1-2-vessel CAD results received lifetime medical treatment without further diagnostics whereas in the stress testing + intervention and CCTA + intervention strategies, patients with these results underwent ICA and received percutaneous coronary intervention. RESULTS: Compared to no screening, the stress testing + medication, stress testing + intervention, CCTA + medication, and CCTA + intervention strategies resulted in 14, 11, 19, and 14 quality-adjusted life days per patient and incremental cost-effectiveness ratios of 49,261, 57,817, 34,887 and 56,518 Euros per quality-adjusted life year (QALY), respectively. Screening only at higher CAD risk thresholds was more cost-effective. Repeated screening was clinically beneficial compared to one-time screening, but only stress testing + medication every 5 years remained cost-effective. At a willingness-to-pay threshold of 83,000 €/QALY (∼ 100,000 US$/QALY), implementing any CAD screening was cost-effective with a probability of 75-95%. CONCLUSIONS: Screening HIV-positive men for CAD would be clinically beneficial and comes at a cost-effectiveness ratio comparable to other accepted interventions in HIV care.

Cardiac stress testing - stress electrocardiography and stress echocardiography.

Coronary artery disease (CAD) affects over 600,000 Australians and is implicated in approximately one in 5 deaths. Coronary angiography is the gold standard for identifying CAD, although it is invasive and not without risk of complication. Cardiac stress testing is useful in the risk stratification of chest pain; noting that 15­39% of angiograms performed are normal.

Association between physician billing and cardiac stress testing patterns following coronary revascularization.

CONTEXT: The degree to which financial factors may influence use of cardiac stress imaging procedures is unknown. OBJECTIVE: To examine the association of physician billing and nuclear stress and stress echocardiography testing following coronary revascularization. DESIGN, SETTING, AND PATIENTS: Using data from a national health insurance carrier, 17,847 patients were identified between November 1, 2004, and June 30, 2007, who had coronary revascularization and an index cardiac outpatient visit more than 90 days following the procedure. Based on overall billings, physicians were classified as billing for both technical (practice/equipment) and professional (supervision/interpretation) fees, professional fees only, or not billing for either. Logistic regression models were used to evaluate the association between physician billing and use of stress testing, after adjusting for patient and other physician factors. MAIN OUTCOME MEASURES: Incidence of nuclear and echocardiographic stress tests within 30 days of an index cardiac-related outpatient visit. RESULTS: The overall cumulative incidence of nuclear or echocardiography stress testing within 30 days of the index cardiac-related outpatient visit following revascularization was 12.2% (95% CI, 11.8%-12.7%). The cumulative incidence of nuclear stress testing was 12.6% (95% CI, 12.0%-13.2%), 8.8% (95% CI, 7.5%-10.2%), and 5.0% (95% CI, 4.4%-5.7%) among physicians who billed for technical and professional fees, professional fees only, or neither, respectively. For stress echocardiography, the cumulative incidence of testing was 2.8% (95% CI, 2.5%-3.2%), 1.4% (95% CI, 1.0%-1.9%), and 0.4% (95% CI, 0.3%-0.6%) among physicians who billed for the technical and professional fees, professional fees only, or neither, respectively. Adjusted odds ratios (ORs) of nuclear stress testing among patients treated by physicians who billed for technical and professional fees and professional fees only were 2.3 (95% CI, 1.8-2.9) and 1.6 (95% CI, 1.2-2.1), respectively, compared with those patients treated by physicians who did not bill for testing (P < .001). The adjusted OR of stress echocardiography testing among patients treated by physicians billing for both or professional fees only were 12.8 (95% CI, 7.6-21.6) and 7.1 (95% CI, 4.0-12.9), respectively, compared with patients treated by physicians who did not bill for testing (P < .001). CONCLUSION: Nuclear stress testing and stress echocardiography testing following revascularization were more frequent among patients treated by physicians who billed for technical fees, professional fees, or both compared with those treated by physicians who did not bill for these services.

Cost-effectiveness of coronary computed tomography and cardiac stress imaging in the emergency department: a decision analytic model comparing diagnostic strategies for chest pain in patients at low risk of acute coronary syndromes.

Emergency department presentations with chest pain are expensive and often unrelated to coronary artery disease (CAD). Coronary computed tomographic angiography (CTA) may allow earlier discharge of low-risk patients, resulting in cost savings. We modeled clinical and economic outcomes of diagnostic strategies in patients with chest pain and at low risk of CAD: exercise electrocardiography (ECG), stress single-photon emission computed tomography (SPECT), stress echocardiography, and a CTA strategy comprising an initial CTA scan with confirmatory SPECT for indeterminate results. Our results suggest that a 2-step diagnostic strategy of CTA with SPECT for intermediate scans is likely to be less costly and more effective for the diagnosis of a patient group at low risk of CAD and a prevalence of 2% to 30%. The CTA strategies were cost saving (lower costs, higher quality-adjusted life-years) compared with stress ECG, echocardiography, and SPECT. Confirming intermediate/indeterminate CTA scans with SPECT results in cost savings and quality-adjusted life-year gains due to reduced hospitalization of patients who returned false-positive initial CTA test. However, CTA may be associated with a higher event rate in negative patients than SPECT, and the diagnostic and prognostic information for the use of CTA in the emergency department is evolving. Large comparative, randomized, controlled trials of the different diagnostic strategies are needed to compare the long-term costs and consequences of each strategy in a population of defined low-risk patients in the emergency department.

A simulation model of clinical and economic outcomes of cardiac CT triage of patients with acute chest pain in the emergency department.

OBJECTIVE: Uncertainty exists as to whether coronary CT angiography (CTA) compared with standard of care (SOC) is more effective and efficient in the triage of low-risk emergency department (ED) patients with acute chest pain. Our objective was to construct a simulation model to estimate clinical and economic outcomes. MATERIALS AND METHODS: We constructed a microsimulation model comparing SOC to coronary CTA-based triage of 1000 55-year-old patients (50% men) with acute chest pain, nonsignificant ECG changes, and initial negative cardiac markers. In SOC, patients were reevaluated with serial cardiac markers after 6-8 hours, followed by either nuclear stress imaging (SPECT) or stress echocardiography. In coronary CTA-based triage, patients were imaged immediately and, depending on the results, discharged, held for SPECT or stress echocardiography, or referred directly to invasive coronary angiography. RESULTS: Compared with SOC, coronary CTA-based triage reduced the number of patients referred for invasive coronary angiography from 406 (SPECT) or 370 (stress echocardiography) to 255 per 1000 and resulted in fewer "missed" cases of acute coronary syndrome overall (5 vs 18). Coronary CTA-based triage also resulted in fewer deaths (4 vs 6). Coronary CTA led to immediate discharge of 706 patients and produced average cost-savings in the ED of $851 (SPECT) or $462 (stress echocardiography) per patient. At 30 days after initial ED triage, coronary CTA-based management produced average savings of $283 (SPECT) and average costs of $292 (stress echocardiography) per patient triaged. CONCLUSION: Our model suggests that coronary CTA-based triage of low-risk patients with acute chest pain in the ED might reduce invasive catheterizations, could improve survival, and may save money.

Stress echocardiography in the district hospital setting: a cost-saving analysis.

AIMS: Accurate and cost-effective techniques are required for investigating patients experiencing chest pain, given the significant workload this patient cohort represents. We determined the cost impact of stress echocardiography compared with myocardial perfusion scintigraphy and coronary angiography in the investigation of patients with chest pain deemed unsuitable for exercise treadmill testing. METHODS AND RESULTS: A total of 200 patients with chest pain-with a low-intermediate probability of coronary artery disease-consecutively referred for stress echocardiography were recruited. Referring clinicians were asked which management strategy they would have chosen were the stress echocardiography service unavailable. The cost saving of stress echocardiography, an accuracy analysis, and adverse outcomes at 6 and 24 months follow-up were determined. The total cost attributable to the stress echocardiography service was Pound Sterling 58 368. If unavailable, 78 (39%) patients would have been referred for angiography and 122 (61%) for perfusion scintigraphy at a cost of Pound Sterling 56 316 and Pound Sterling 42 090, respectively, with a total cost of Pound Sterling 98 406. This represents a cost saving of Pound Sterling 40 038. CONCLUSION: Stress echocardiography is a cost saving method for the investigation of chest pain in patients with low-intermediate risk of flow limiting coronary artery disease in the district hospital setting.