Clinical and cost effectiveness of coronary angiography for the primary diagnosis of obstructive coronary artery disease with low and moderate pretest probability

Background. The detection rate of obstructive changes in the coronary arteries in patients with suspected coronary artery disease (CAD) during invasive examination remains low, resulting in an unjustified increase in the burden on healthcare facilities. A study of the clinical and cost effectiveness of strategies for the primary diagnosis of CAD determines the prospects for optimizing patient routing processes and reducing costs in the healthcare system.

Aims — to evaluate the clinical and cost effectiveness of invasive coronary angiography (ICA) in patients with suspected obstructive CAD.

Methods. The retrospective study included 620 patients with low and moderate pretest probability (PTP) of CAD aged ≥ 18 years who underwent elective ICA at the Almazov National Medical Research Centrе from January to May 2025. According to the results of ICA, CAD was considered obstructive if coronary artery stenosis ≥ 50% was detected. To carry out economic calculations based on the results of ICA, two groups of patients were formed. The first group consisted of 335 patients with obstructive CAD, and the second group consisted of 285 patients without obstructive changes in the coronary arteries. Direct medical costs for inpatient ICA were calculated. The potential costs of a diagnostic strategy using coronary computed tomography angiography (CCTA) were assessed as a comparison method. Cost effectiveness analysis was performed using the tariff method of cost estimation and the cost minimization method.

Results. The clinical effectiveness of ICA in the examined cohort of patients with suspected CAD was 54%. Myocardial revascularization was performed in 38.1% of cases. An invasive strategy for the primary diagnosis of CAD is less effective than CCTA. Using a noninvasive approach, cost savings reach 17.7% of the total cost of ICA.

Conclusions. In real clinical practice, the detection rate of obstructive CAD remains low during routine invasive examination. This study demonstrates the lack of cost effectiveness of the invasive approach in patients with suspected CAD. Non-invasive CCTA in low and moderate PTP of obstructive CAD may be a promising tool for optimizing the clinical and cost effectiveness of algorithms for verifying coronary atherosclerosis by reducing the number of ICA and increasing its diagnostic value.