Background The coronary artery calcium score (CAC) predicts future coronary heart disease (CHD) events and could be used to guide primary prevention interventions, but CAC measurement has costs and exposes patients to low-dose radiation. Methods and Results We estimated the cost-effectiveness of measuring CAC and prescribing statin therapy based on the resulting score under a range of assumptions using an established model enhanced with CAC distribution and risk estimates from the Multi-Ethnic Study of Atherosclerosis (MESA). Ten years of statin treatment for 10,000 55-year-old women with high cholesterol (10-year CHD risk=7.5%) was projected to prevent 32 myocardial infarctions, cause 70 cases of statin-induced myopathy, and add 1,108 years to total life-expectancy. Measuring CAC and targeting statin treatment to the 2,500 women with CAC>0 would provide 45% of the benefit (+501 life-years), but CAC measurement would cost $2.25 million and cause 9 radiation-induced cancers. Treat All was preferable to CAC screening in this scenario and across a broad range of other scenarios (CHD risk=2.5-15%) when statin assumptions were favorable ($0.13/pill and no quality of life penalty). When statin assumptions were less favorable ($1.00/pill and disutility=0.00384), CAC screening with statin treatment for persons with CAC>0 was cost-effective (<$50,000/quality-adjusted life-year) in this scenario, in 55-year old men with CHD risk=7.5%, and in other intermediate risk scenarios (CHD risk=5-10%). Our results were critically sensitive to statin cost and disutility, and relatively robust to other assumptions. Alternate CAC treatment thresholds (>100 or >300) were generally not cost-effective. Conclusions CAC testing in intermediate risk patients can be cost-effective, but only if statins are costly or significantly impact quality of life.

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Background and Purpose-Better selection of patients for intravenous recombinant tissue plasminogen activator (IV tPA) treatment may improve clinical outcomes. We examined the cost-effectiveness of adding penumbral-based MRI to usual computed tomography (CT)-based methods to identify patients for IV tPA treatment. Methods-A decision-analytic model estimated the lifetime costs and outcomes associated with penumbral-based MRI selection in a patient population similar to that enrolled in the IV tPA clinical trials. Inputs were obtained from published literature, clinical trial data, claims databases, and expert opinion. Outcomes included cost per life-year saved and cost per quality-adjusted life-year (QALY) gained. Costs and outcomes were discounted at 3% annually. Sensitivity analyses were conducted. Results-The addition of penumbral-based MRI selection increased total cost by $103 over the patient's remaining lifetime.Penumbral-based MRI selection resulted in favorable outcomes (modified Rankin Scale Յ1) more often than CT-based selection (36.66% versus 35.06%) with an incremental cost per life year of $1840 and an incremental cost per QALY of $1004. Multivariate sensitivity analysis predicted cost-effectiveness (Յ$50 000 per QALY) in 99.7% of simulation runs. Conclusions-Selecting ischemic stroke patients for IV tPA treatment using penumbral-based MRI after routine CT may increase overall acute care costs, but the benefit is large enough to make this highly cost-effective. This economic analysis lends further support to the consideration of a paradigm shift in acute stroke evaluation.