Cost-Effectiveness of Magnetocardiography in Diagnosis of Coronary Artery Disease in Patients with Chest Pains

Abstract

Coronary Artery Disease (CAD) is a leading cause of death worldwide. Early detection has been shown to be critical in preventing CAD-related deaths. Magnetocardiography (MCG) is often favoured for its non-invasiveness and high sensitivity in the current diagnosis of CAD. Despite the popularity of MCG, an analysis of its cost-effectiveness in comparison with other non-invasive methods has not yet been performed. To estimate the potential cost effectiveness of MCG in CAD patients, specifically in those with chest pain, cost-effectiveness analyses of selected non-invasive methods (Stress-ECG, Stress-Scintigraphy and Stress-EchoCG) were performed and compared. The analysis revealed that MCG shows the lowest cost-effectiveness ratios, indicating it is the most efficient diagnostic method amongst non-invasive cardiographs. Furthermore, our analysis revealed that MCG is the most cost efficient method even for patients with symptomatic indication of CAD (e.g. chest pain), either on its own or in combination with coronary angiographs. These results suggest MCG is a highly most economical non-invasive diagnostic method, and can improve the quality of CAD diagnosis.

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Citation: Chaikovsky IA, Pryimak VM, Verba AV, Lutay MI, Budnyk MM, Mjasnikov GV, et al. Cost-Effectiveness
of Magnetocardiography in Diagnosis of Coronary Artery Disease in Patients with Chest Pain. Austin Cardiol.
2016; 1(1): 1003.
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Abstract
Coronary Artery Disease (CAD) is a leading cause of death worldwide.
Early detection has been shown to be critical in preventing CAD-related deaths.
Magnetocardiography (MCG) is often favoured for its non-invasiveness and high
sensitivity in the current diagnosis of CAD. Despite the popularity of MCG, an
analysis of its cost-effectiveness in comparison with other non-invasive methods
has not yet been performed. To estimate the potential cost effectiveness of
MCG in CAD patients, specically in those with chest pain, cost-effectiveness
analyses of selected non-invasive methods (Stress-ECG, Stress-Scintigraphy
and Stress-EchoCG) were performed and compared. The analysis revealed
that MCG shows the lowest cost-effectiveness ratios, indicating it is the most
efcient diagnostic method amongst non-invasive cardiographs. Furthermore,
our analysis revealed that MCG is the most cost efcient method even for
patients with symptomatic indication of CAD (e.g. chest pain), either on its own
or in combination with coronary angiographs. These results suggest MCG is a
highly most economical non-invasive diagnostic method, and can improve the
quality of CAD diagnosis.
Keywords: Magnetocardiography; Cost-effectiveness analysis; Coronary
artery disease; Non-invasive diagnostic methods
Abbreviations
MCG: Magnetocardiography; CAD: Coronary Artery
Disease; CEA: Cost-Eectiveness Analysis; Stress-ECG: Stress
Electrocardiography; Stress-scintigraphy: Stress Scintigraphy Test
with Tallium; Stress-EchoCG: 2D Echocardiography and Load Test
with Treadmill; RISK: Risk of Essential Cardiovascular Failures
Provoked by Given Diagnostic Method; CA: Coronary Angiography;
CER: Cost-Eectiveness Ratio; PREV: Prevalence; SENS: Sensitivity;
SPEC: Specicity
Introduction
Cardiovascular complications represent one of the leading cause
of death worldwide, and they are estimated to cause 23.3 million
deaths by 2030 [1]. Coronary Artery Disease (CAD) is the most
common cause of death among cardiovascular complications, and
indeed it accounted for more than 16.8% of all deaths worldwide in
2013 [2]. CAD has also been associated with important morbidity and
mortality related to stroke, ischemia, embolism and heart failure [3].
e number of cases of CAD is especially high in developed countries.
According to the Global Burden of Disease Study 2010, ischemic
heart disease and stroke are the most prevalent diseases in Ukraine.
In the United States, CAD is the most common cause of death in
men and women over 20 years of age, contributing to 370,000 deaths
annually [4].
Especially concerning is the fact that the prevalence of CAD is
increasing [5]. Moreover, the identication of the mechanisms by
which CAD results in untimely deaths, as well as the development of
safe and eective therapies to combat it, remain elusive. Developing
innovative therapeutics targeting CAD is a priority, and much
Research Article
Cost-Effectiveness of Magnetocardiography in Diagnosis
of Coronary Artery Disease in Patients with Chest Pain
Chaikovsky IA1*, Pryimak VM2, Verba AV3, Lutay
MI5, Budnyk MM1, Mjasnikov GV4, Kazmirchyk
AP4, Kovalenko AS1, Bae JSH6 and Ji Wenming7
1Glushkov Institute of Cybernetics, Ukraine
2Shevchenko National University of Kyiv, Ukraine
3Military Medical Department, Ministry of Defense,
Ukraine
4National Military Medical Clinical Center, Ukraine
5National Research Center, Strazheshesko Institute of
Cardiology, Ukraine
6University of Oxford, UK
7Cardiomox, UK
*Corresponding author: Illya Chaikovsky, Glushkov
Institute of Cybernetics, 40 Glushkov Ave., 03680, Kyiv-
187, Ukraine
Received: September 16, 2016; Accepted: December
09, 2016; Published: December 13, 2016
eort has been expended in identifying prophylactic measures and
pharmacological approaches for disease management. While the
methods of early CAD diagnosis have been signicantly improved,
stress echocardiography, followed by Coronary Angiograph (CA),
remain the most favourable methods of diagnosis in symptomatic
patients. However, the recent development of Magnetocardiography
(MCG) - a non-invasive cardiac-activity mapping technique - has led
to increased detection sensitivity via increased numbers of recording
sites as compared to other non-invasive cardiographs. MCG can detect
even slight changes in the electrophysiology of the myocardium, and
allows for the visualization of cardiac electrophysiological processes
without any external inuence [6]. MCG also provides information
on the magnetic signature produced by the vortex currents in the
myocardium, which cannot be registered by Electrocardiography
(ECG) [7]. ese unique advantages of MCG make it an attractive
technique for CAD detection and it has contributed to the current
understanding of the generation, localization, and dynamic
behaviours of cardiac currents in CAD patients.
Common non-invasive techniques to diagnose CAD include
Stress Induced Electrocardiography (stress-ECG), Echocardiography
(stress-EchoCG) and Scintigraphy (stress-scintigraphy). e choice
of one method over another depends on cost-eectiveness and
resource consideration. Generating a generic model that can estimate
the comparative cost eectiveness of a screening technique would
thus provide a valuable tool to assess the opportunity cost of a
medical intervention on the health care system [8]. In order to make
a comparison amongst the current non-invasive cardiographs, this
study aimed to perform a Cost Eectiveness Analysis (CEA) for several
methods (Stress-ECG, Stress-EchoCG, and Stress-Scintigraphy) and

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to compare them with the MCG, the most modern non-invasive CAD
diagnostic technique.
Methods
Statistical denitions
e research was conducted under the following terms:
1. Prevalence (PREV) of CAD: estimated to be 10% in this
theoretical model [9].
2. α = 1 – Sensitivity (SENS): represents the probability of the
diagnostic method correctly detecting patients with CAD.
3. β = 1 – Specicity (SPEC): represents the probability of the
diagnostic method correctly detecting patients without CAD.
Total probability of false diagnosis for CAD
Health economic evaluations include uncertainty for both positive
and false parameters of observable variables. In order to determine
the total probability of establishing a false diagnosis, we have built
a generalized model to combine both sensitivity and specicity to
analyze the likelihood of an error [10]:
(1)
Total probability of false diagnosis for CAD in patients
with symptomatic indications
e most common symptom of CAD is chest pain, described as
chest discomfort, aching, and heaviness in the chest [11]. Since the
presence of disease symptoms can bias the selection of a method
of diagnosis, prevalence – which measures the probability of a
randomized occurrence of CAD - is not an accurate measurement
in our model. Pretest Probability (PP), determined by the Mayo
Clinic Index (MCI) from 2002, was used instead to calculate the total
probability of false diagnosis of CAD in patients with chest pain [12].
(2)
Cost-effectiveness ratio
Diagnostic accuracy incorporates parameters of Specicity
(SPEC), Sensitivity (SENS) and Prevalence (PRV) when measuring
the eectiveness of a method. To determine the diagnostic accuracy
of non-invasive methods used in medical practice for the diagnosis of
CAD, we calculated predictive indexes using values of sensitivity and
specicity derived from the literature [13,14]:
(3)
(4)
where NPV is a negative predictive value (rate of coincidence of
negative test results under the absence of CAD); PPV is a positive
predictive value (rate of coincidence of positive test results under
the presence of CAD); SPEC and SENS - specicity and sensitivity,
respectively; PREV - the prevalence of CAD; α and β -probability of
the diagnostic method correctly detecting patients with or without
CAD, respectively.
Based on formulas 3 and 4, the average of the diagnostic
eectiveness was calculated [13,14]:
(5)
e Cost-Eectiveness Ratio (CER) of each diagnostic method
was also calculated:
(6)
Substituting the calculated value of eect (5) above, we can
reformulate the CER as the following:
(7)
Ratio for cost-effectiveness increments
e Incremental Cost-Eective Ratio (ICER) provides the
summarized cost-eectiveness of a health care intervention by
comparing the CER of two diagnostic methods. For this analysis, we
have calculated the coecient ratio between the MCG and other non-
invasive cardiographs using the following equation:
(8)
where ICER is the incremental cost-eectiveness ratio; Cost(MCG)
is the relative cost of MCG; Cost(NIM) is the relative cost of another
non-invasive method; Eect(MCG) is the diagnostic accuracy of MCG;
Eect(NIM) is the diagnostic accuracy of another non-invasive method.
Relative cost of non-invasive diagnosis followed by
coronary angiography
e accuracy of a non-invasive method to diagnose CAD can be
uncertain due to the sensitivity and specicity of the method, as well
as the severity of the disease symptoms. In most cases, 70% to 90%
of diagnoses using non-invasive methods still require a CA to fully
conrm the presence of CAD. erefore, we have further modied
the generated formula to calculate the relative probable cost for
patients with or without CAD when undergoing both invasive and
non-invasive diagnostic methods.
e relative cost of a false diagnosis for patients without
symptomatic implications was calculated using:
(9)
(10)
e relative cost of a false diagnosis for patients with symptomatic
implications was calculated using:
(11)
(12)
where PREV is the prevalence of CAD; PP is the pretest
probability of CAD based on symptomatic indication; α and β are
the probability of the diagnostic method correctly identifying patients
with or without CAD, respectively; α(CA) and β(CA) (both = 0.001) are
the probability of false positive and negative diagnosis, respectively
[15]; Cost (CA) is the cost of the coronary angiograph.
Results
Total probability of false diagnosis for CAD using selected
non-invasive methods
To establish the overall eectiveness of selected medical
interventions, both diagnostic accuracy and cost were evaluated
for the purpose of this study. e cost-eectiveness of MCG was

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compared with that of other non-invasive methods, namely Stress-
ECG, Stress-scintigraphy and Stress-EchoCG, to determine which
method is the most accurate with the lowest cost. Sensitivity (SENS)
and Specicity (SPEC), derived from previously reported analyses
[13,14], and the relative costs of examinations were compared in
Table 1.
To include the possibility of a false diagnosis, the total probability
of a false diagnosis for each non-invasive method was rst calculated
from the generated model above (1, 2) (Figure 1).
We observed that the stress induced ECG method (Perror = 24%)
resulted in the highest probability of false diagnosis, while stress
induced EchoCG exhibited the lowest (Perror = 13%). When symptoms
of chest pain were present, MCG showed the lowest probability of
false diagnosis in comparison to other non-invasive diagnostic
methods (Perror = 15%). e probability of false diagnosis between
stress induced EchoCG and MCG was not statistically dierent,
indicating that the two methods have a similar rate of misdiagnosis.
Relative costs of false diagnosis using selected non-
invasive methods in combination with coronary
angiography
Conventional X-ray CA is the standard of reference for the
assessment of CAD. e ability of a CA to detect both the exact location
of CAD as well as the severity of the disease makes it an attractive
method to conrm CAD diagnosis. erefore, even aer the usage
of a non-invasive method, a CA is oen performed to validate the
diagnosis. Although we observed that MCG has the lowest probability
of false diagnosis, the relative cost of an individual diagnosis using
MCG is neither accurate nor realistic in current medical practice,
as CA is oen used in conjunction with a non-invasive technique.
erefore, we conducted a further analysis comparing the relative
cost of false diagnosis using non-invasive diagnostic methods in
combination with CA (Figure 2).
Our assessment revealed that the MCG + CA diagnostic
combination has the lowest relative cost of false diagnosis (0.145).
e stress induced ECG + CA combination exhibited the second
lowest cost, (0.167), making it 15% more expensive than MCG +
CA. Stress-scintigraphy + CA had the highest relative cost of false
diagnosis (0.685), making the cost 370% greater than MCG + CA. In
patients with CAD, the relative costs of false diagnosis were found to
be minimal, yet MCG still exhibited the lowest relative cost amongst
the non-invasive methods (Figure 3).
When patients presented with symptomatic indications of CAD
(e.g. chest pain), patients without CAD had relatively lower costs
Diagnostic method Sensitivity (SENS) Specicity (SPEC) Risk Relative cost of examination (Cost) Reference
MCG 0.93 0.84 0.0 % 1 [15]
Stress-ECG 0.68 0.77 0.05% 0.8 [16]
Stress-SCN 0.90 0,77 0.05% 3.3 [16]
Stress-EchoCG 0.84 0,87 0.05% 2.5 [16]
CA 0.99 0.99 1.5 % 7.8 [16]
Table 1: Statistical Measures, Risks and Relative Costs for CAD diagnostic methods.
Diagnostic method Predictive value Effectiveness Relative Cost Cost-Effectiveness Ratio,
CER
∆ Cost= Cost(MCG)–
Cost
∆ Effect =Effect(MCG) –
Effect2 ICER
PPV NPV
MCG 0.39 0.99 0.69 1 1.4 - - -
Stress-ECG 0.25 0.96 0.605 0.8 1.3 0.20 0.09 2.40
Stress-SCNT 0.30 0.99 0.645 3.3 5.1 -2.30 0.05 -51.1
Stress-EchoCG 0.42 0.98 0.70 2.5 3.6 -1.50 -0.01 150
Table 2: Comparison of cost-effectiveness ratios among non-invasive diagnostic methods of CAD.
MCG
S tre s s-E C G
S tre s s-Sci ntigraphy
Stres s -EchoC G
0
10
20
30
Tota l Pr obaility of F als e Diagno sis (% )
No Symptom
Chest Pain
15
24 22
13
12
27
17 14
Figure 1: Total probability of false diagnoses for CAD by non-invasive
methods.
MCG + C A
S tre s s-E C G + C A
S tre s s -S cinti gra ph y + CA
S tre s s-E c hoC G + C A
0.0
0.2
0.4
0.6
0.8
R ela tive C os t of Fa lse Dia gnos is
No Symptom
Chest Pain
0.150 0.170
0.690
0.293
0.084 0.097
0.396
0.169
Figure 2: Relative costs of false diagnosis of CAD using a combined non-
invasive method and CA.
ECG: Electrocardiography; EchoCG: Echocardiography; CAD: Coronary
Artery Disease; MCG: Magnetocardiography; CA: Coronary Angiography.

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of false diagnosis than patients without symptoms. Furthermore,
symptomatic indications did not alter the overall trend; only the
relative cost of false diagnosis was decreased. On the other hand,
patients with CAD had increased relative costs of false diagnosis
when presented with chest pain. is is expected, as CA is oen
the commonly used diagnostic method, and thus having additional
non-invasive procedures is considered unnecessary and only adds
additional costs.
Cost-effectiveness analysis (CEA) for non-invasive
diagnostic methods of CAD
Incremental cost-eectiveness ratios amongst the non-invasive
diagnostic methods of CAD were used to make direct comparisons
of each method’s cost eectiveness (Table 2). From our generated
model, MCG and stress-ECG had cost-eectiveness ratios of 1.4 and
1.3, respectively. Stress-EchoCG had a cost eectiveness ratio of 3.6,
and stress-scintigraphy exhibited the highest ratio of 5.1. We next
compared the ICER value of MCG to those of other non-invasive
CAD diagnostic methods, and found all the ratios generated by this
comparison were greater than 1 (ICER > 1). An ICER value greater
than 1 indicates that the dierence in the diagnostic eectiveness of
MCG versus other non-invasive methods is lower than the dierence
in their costs, thus demonstrating that MCG is the most cost-eective
diagnostic method amongst those studied.
Discussion
Clinical economic analyses are necessary to justify healthcare
costs. Indeed, medical decisions must now factor in healthcare costs
in addition to clinical considerations. Marginal costs - the costs of
providing an additional unit of service - for each medical diagnosis
need to be carefully considered before an assessment is initiated.
In the case of CAD, advances in the technology of non-invasive
coronary artery imaging devices have improved early detection of
subclinical cases. However, a comprehensive model that compares
the cost-eectiveness of each non-invasive method has not been
previously reported. e analysis presented in this study focused
on comparing the cost-eectiveness and the relative cost of false
diagnosis for each non-invasive method. Simple diagnostic analyses
of the economic consequences of health benets over cost, however,
require a number of assumptions, and for this reason these analyses
are rarely straight forward. In order to create a comprehensive model
that compares the eectiveness of each medical diagnostic method,
we have formulated a number of generic models that incorporate the
following essential aspects: medical - characterized by the accuracy of
the treatment, diagnosis, and frequency of rehabilitation; economical
- measured by the nancial medical cost and the opportunity cost for
rehabilitation; and sociality - assessed by the patient’s quality of life
aer the treatment.
Our analysis demonstrates that under most assumptions, MCG
is the most cost-eective non-invasive diagnostic method for CAD.
While MCG has a higher cost than stress-ECG, it is more accurate and
eective, thus overall making it a better, more cost-eective diagnostic
tool. e probability of a false diagnosis using MCG was the lowest
among other non-invasive procedures. Lastly, a quantitative overview
of the Incremental Cost-Eectiveness Ratio (ICER) indicated that
other non-invasive methods have a ratio greater than 1 in comparison
to MCG. ese evaluations suggest that MCG has the most optimal
and practical benets in relation to its cost. Other non-invasive
methods, such as stress induced EchoCG (ICER = 150), however, are
not recommended due to their low practicality and high costs.
Further analysis using a combination both non-invasive and
invasive methods, specically CA, were performed to compare
relative costs of false diagnosis. CA is the most standard test for
identifying the presence and extent of atherosclerotic CAD, and
therefore, it is oen implemented in combination with a non-invasive
method. Our results indicate that in the case of false diagnosis, the
highest relative cost for combination therapy occurs with stress-
induced scintigraphy and CA. MCG and CA combination diagnostic
methods, on the other hand, exhibited the lowest relative cost of false
diagnosis (> 4 fold less than stress-scintigraphy + CA). e overall
relative costs for false diagnosis were lower when patients had CAD
symptomatic indications than when they did not. However, the trend
was the same whether the patients had symptoms of CAD or not;
stress-scintigraphy had the highest cost, while MCG had the lowest.
ese results illustrate that the MCG is the least expensive method
when used in conjunction with CA, suggesting it should be the rst
line of diagnosis for CAD.
Cost-eectiveness analyses have strengths and limitations. e
limitations of our study include the generalized assumption that
the eectiveness of a diagnostic method can be quantied by the
number of successfully identied clinical cases it detects. We did not
consider any restrictions and weaknesses of each diagnostic method,
including motion artifacts and so tissue attenuation. Possible side
eects, complications, and risks, involving, for example, the exposure
to radiation with CA, were not included in the analysis. erefore, a
more sophisticated approach would have been generated if references
to these costs were available. Nevertheless, CEA provides an overall
comparison of the net benet of each medical diagnosis. is method
of analysis has become the most commonly used metric of health
impact and is oen applied by the World Health Organization
(WHO) for their evaluations [16].
Our ndings may provide crucial clinical considerations for
health care providers, as they are frequently presented with an array
of diagnostic methods. Cost-benet analysis is therefore highly useful
in implementing medical diagnostic techniques that are most cost-
eective for both patients and public health ocials. Our results
MCG + C A
Stress -E C G + C A
Stres s - S ci ntigr aph y + CA
S tres s - E ch oC G + CA
0.00
0.05
0.10
0.15
0.20
0.25
R ela tive C os t of F als e D iagnos is
No Symptom + CAD
Chest Pain + CAD
0.007 0.026 0.033 0.040
0.034
0.125
0.158
0.192
Figure 3: Relative costs of false diagnosis in patients with chest pain using
combined non-invasive method and CA.
ECG: Electrocardiography; EchoCG: Echocardiography; CAD: Coronary
Artery Disease; MCG: Magnetocardiography; CA: Coronary Angriography.

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demonstrate that the MCG has considerably lower cost-benet ratios
in comparison to other non-invasive methods, and the high accuracy
and non-invasive properties of MCG makes it the most attractive non-
invasive method to diagnose CAD under current clinical parameters.
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Citation: Chaikovsky IA, Pryimak VM, Verba AV, Lutay MI, Budnyk MM, Mjasnikov GV, et al. Cost-Effectiveness
of Magnetocardiography in Diagnosis of Coronary Artery Disease in Patients with Chest Pain. Austin Cardiol.
2016; 1(1): 1003.
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