The Decision Concerning Coronary Angiography in Patients with Chest Pain

We examined the decision whether to perform coronary angiography (followed by bypass surgery if appropriate findings are present) in middle-aged men who have chest pain and have undergone exercise tolerance testing (ETT). We developed a model of this decision that combines data from a variety of sources and selects the optimal strategy based on health out come and, if desired, monetary cost. The analysis supports the following conclusions: (1) for patients with nonspecific chest pain or atypical angina, the ETT provides useful infor mation concerning the decision, furthermore, the number of millimeters of ST-segment depression above which angiography should be performed depends on coronary risk factors and pain severity. (2) A normal ETT is insufficient evidence to exclude coronary angiogra phy for patients with typical angina, provided that one is willing to expend resources for health benefits at levels comparable to those for other accepted medical practices. (3) If monetary considerations are excluded, the preceding statement concerning ETT and angiography also holds for patients with atypical angina and for those with nonspecific pain and advanced risk factors. These last two conclusions suggest that ETT is not useful in guid ing management decisions concerning coronary angiography in patients at high enough risk of coronary artery disease on the basis of symptoms and risk profile. (Med Decis Making 5:293-309, 1986)