Opportunities to Improve Health Economic Outcomes in Coronary Artery Disease: A Review of Care Pathways in the United States Healthcare System

Main Article Content

Sebastian M Haberkorn, MD Marjan J.M. Hummel, PhD Bianca T. A. de Greef, MD Jennifer Franke, MD Ramon J. Pesigan, MD Pearl Vyas, MD Aparna Kulkarni, MD


Background: Despite medical advances, coronary artery disease remains the leading cause of death worldwide. Evidence suggests that current uptake and efficacy of strategies in coronary care are suboptimal. This review aimed to investigate key areas for improvements in coronary care in the United States, and to estimate the potential health gains if existing strategies were improved.

Methods: A targeted literature review of the acute and chronic coronary artery disease  care pathways was conducted to identify areas where health outcomes could be improved in the United States if uptake or efficacy of existing strategies were optimal.  Using hypothetical scenarios of maximally improved efficacy or uptake from published literature and health impact modeling, we calculated potential additional lives saved and potential reductions in direct medical costs, using Medicare rates as proxy, if improvements were realized.

Results: We identified the following areas where improvements in uptake or efficacy of existing strategies could positively impact coronary artery disease  outcomes in the United States: primary prevention, early detection, efficient diagnosis, reducing time to reperfusion, and secondary prevention. Improvements in primary and secondary coronary artery disease  prevention have the potential to reduce annual direct medical costs by approximately $17 billion USD and $5 billion USD, respectively. Further, if the efficacy of existing preventive strategies was improved to 80%, then 102,000 (primary prevention) and 32,000 (secondary prevention) lives could be saved annually. Improvements in early detection, more efficient diagnosis, and reducing time to reperfusion could also substantially increase lives saved by increasing the uptake and efficacy of timelier percutaneous interventions, and potentially reduce annual direct medical costs by $1 billion USD.

Conclusions: Improvements in primary prevention offer the greatest potential for lives saved and medical costs avoided. Future innovations should focus on advancing existing primary preventive strategies, while simultaneously driving innovation towards developing effective novel strategies in each of the key areas for improvement.

Article Details

How to Cite
HABERKORN, Sebastian M et al. Opportunities to Improve Health Economic Outcomes in Coronary Artery Disease: A Review of Care Pathways in the United States Healthcare System. Medical Research Archives, [S.l.], v. 12, n. 6, june 2024. ISSN 2375-1924. Available at: <https://esmed.org/MRA/mra/article/view/5276>. Date accessed: 22 july 2024. doi: https://doi.org/10.18103/mra.v12i6.5276.
Review Articles


1. Centers for Disease Control and Prevention. Heart disease in the United States. https://www.cdc.gov/heartdisease/facts.htm. 2022. Accessed 31 August
2. Roth GA, Mensah GA, Johnson CO, Addolorato G, Ammirati E, Baddour LM, Barengo NC, Beaton AZ, Benjamin EJ, Benziger CP, et al. Global burden of cardiovascular diseases and risk factors, 1990-2019: Update from the GBD 2019 study. J Am Coll Cardiol. 2020;76:2982–3021. Doi: 10.1016/j.jacc.2020.11.010
3. Tsao CW, Aday AW, Almarzooq ZI, Anderson CAM, Arora P, Avery CL, Baker-Smith CM. Heart disease and stroke statistics - 2023 update: A report from the American Heart Association. Circulation. 2023;147:e93-e621. Doi: 10.1161/CIR.0000000000001123
4. Centers for Disease Control and Prevention. About heart disease. https://www.cdc.gov/heartdisease/about.htm. 2022. Accessed 31 August
5. Becker D, Sharma P, Kilgore M, Yurgin N. Real-world costs for first and recurrent events of myocardial infarction and stroke in the elderly Medicare population. J Clin Lipidol. 2015;9:454. Doi: 10.1016/j.jacl.2015.03.072
6. Unsar S, Sut N, Durna Z. Health-related quality of life in patients with coronary artery disease. J Cardiovasc Nurs. 2007;22:501–507. Doi: 10.1097/01.JCN.0000297382.91131.8d
7. Amini M, Zayeri F, Salehi M. Trend analysis of cardiovascular disease mortality, incidence, and mortality-to-incidence ratio: results from global burden of disease study 2017. BMC Public Health. 2021;21:401. Doi: 10.1186/s12889-021-10429-0
8. Lindstrom M, DeCleene N, Dorsey H, Fuster V, Johnson CO, LeGrand KE, Mensah GA, Razo C, Stark B, Varieur Turco J, et al. Global burden of cardiovascular diseases and risks collaboration, 1990–2021. J Am Coll Cardiol. 2022;80:2372–2425.
Doi: 10.1016/j.jacc.2022.11.001
9. McClellan M, Brown N, Califf RM, Warner JJ. Call to Action: Urgent challenges in cardiovascular disease: a presidential advisory from the American Heart Association. Circulation. 2019;139:e44–e54. Doi: 10.1161/CIR.0000000000000652
10. Pereira M, Azevedo A, Lunet N, Carreira H, O'Flaherty M, Capewell S, Bennett K. Explaining the decline in coronary heart disease mortality in Portugal between 1995 and 2008. Circ Cardiovasc Qual Outcomes. 2013;6:634–642. Doi: 10.1161/CIRCOUTCOMES.113.000264
11. Hotchkiss JW, Davies CA, Dundas R, Hawkins N, Jhund PS, Scholes S, Bajekal M, O'Flaherty M, Critchley J, Leyland AH, et al. Explaining trends in Scottish coronary heart disease mortality between 2000 and 2010 using IMPACTSEC model: retrospective analysis using routine data. BMJ. 2014;348:g1088. Doi: 10.1136/bmj.g1088
12. Koopman C, Vaartjes I, van Dis I, Verschuren WM, Engelfriet P, Heintjes EM, Blokstra A, Deeg DJ, Visser M, Bots ML, et al. Explaining the decline in coronary heart disease mortality in the Netherlands between 1997 and 2007. PLoS One. 2016;11:e0166139. Doi: 10.1371/journal.pone.0166139
13. Psota M, Bandosz P, Goncalvesova E, Avdicova M, Bucek Psenkova M, Studencan M, Pekarcikova J, Capewell S, O'Flaherty M. Explaining the decline in coronary heart disease mortality rates in the Slovak Republic between 1993-2008. PLoS One. 2018;13:e0190090. Doi: 10.1371/journal.pone.0190090
14. Frieden TR. A framework for public health action: the health impact pyramid. Am J Public Health. 2010;100:590–595. Doi: 10.2105/AJPH.2009.185652
15. American College of Cardiology. ACC/AHA primary prevention guideline provides playbook for managing cv risk factors. https://www.acc.org/latest-in-cardiology/articles/2019/03/08/15/32/sun-2pm-acc-aha-release-first-guideline-primary-prevention-cvd-gl-prevention. 2019. Accessed 31 August
16. World Heart Federation. What can you do to lower your risk of cardiovascular disease? https://world-heart-federation.org/what-we-do/prevention/. Accessed 31 August
17. Taylor F, Huffman MD, Macedo AF, Moore TH, Burke M, Davey Smith G, Ward K, Ebrahim S. Statins for the primary prevention of cardiovascular disease. Cochrane Database Syst Rev. 2013;2013:CD004816. Doi: 10.1002/14651858.CD004816.pub5
18. Kazzi B, Feldman D, Blumenthal RS. The effect of statin therapy on the progression and composition of coronary atherosclerotic plaque identifed on coronary CTA. In: Cardiology ACo, ed.; 2021
19. Eze-Nliam CM, Zhang Z, Weiss SA, Weintraub WS. Cost-effectiveness assessment of cardiac interventions: determining a socially acceptable cost threshold. Interv Cardiol (Lond). 2014;6:45–55. Doi: 10.2217/ica.13.81
20. Chou R, Dana T, Blazina I, Daeges M, Bougatsos C, Grusing S, Jeanne TL. In: Statin Use for the Prevention of Cardiovascular Disease in Adults: A Systematic Review for the U.S. Preventive Services Task Force. Rockville (MD); 2016.
21. Nunes JP. Statins in primary prevention: impact on mortality. A meta-analysis study. Minerva Cardioangiol. 2017;65:531–538. Doi: 10.23736/S0026-4725.17.04323-7
22. Gaba P, Bhatt DL, Steg PG, Miller M, Brinton EA, Jacobson TA, Ketchum SB, Juliano RA, Jiao L, Doyle RT, Jr., et al. Prevention of cardiovascular events and mortality with icosapent ethyl in patients with prior myocardial infarction. J Am Coll Cardiol. 2022;79:1660–1671. Doi: 10.1016/j.jacc.2022.02.035
23. Werba JP, Giroli MG, Simonelli N, Vigo L, Gorini A, Bonomi A, Veglia F, Tremoli E. Uptake and effectiveness of a primary cardiovascular prevention program in an underserved multiethnic urban community. Nutr Metab Cardiovasc Dis. 2022;32:1110–1120. Doi: 10.1016/j.numecd.2022.01.013
24. Virani SS, Alonso A, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Chang AR, Cheng S, Delling FN, et al. Heart disease and stroke statistics-2020 update: A report from the American Heart Association. Circulation. 2020;141:e139–e596. Doi: 10.1161/CIR.0000000000000757
25. Penning-van Beest FJ, Termorshuizen F, Goettsch WG, Klungel OH, Kastelein JJ, Herings RM. Adherence to evidence-based statin guidelines reduces the risk of hospitalizations for acute myocardial infarction by 40%: a cohort study. Eur Heart J. 2007;28:154–159. Doi: 10.1093/eurheartj/ehl391
26. Hirsh BJ, Smilowitz NR, Rosenson RS, Fuster V, Sperling LS. Utilization of and adherence to guideline-recommended lipid-lowering therapy after acute coronary syndrome: Opportunities for improvement. J Am Coll Cardiol. 2015;66:184–192. Doi: 10.1016/j.jacc.2015.05.030
27. Colantonio LD, Rosenson RS, Deng L, Monda KL, Dai Y, Farkouh ME, Safford MM, Philip K, Mues KE, Muntner P. Adherence to statin therapy among US adults between 2007 and 2014. J Am Heart Assoc. 2019;8:e010376. Doi: 10.1161/JAHA.118.010376
28. 28. Zhao B, He X, Wu J, Yan S. Adherence to statins and its impact on clinical outcomes: a retrospective population-based study in China. BMC Cardiovasc Disord. 2020;20:282. Doi: 10.1186/s12872-020-01566-2
29. Decision Resource Group. Market Insights. Interventional Cardiology Devices US. 30 September 2020.
30. Svendsen MT, Boggild H, Skals RK, Mortensen RN, Kragholm K, Hansen SM, Riddersholm SJ, Nielsen G, Torp-Pedersen C. Uncertainty in classification of death from fatal myocardial infarction: A nationwide analysis of regional variation in incidence and diagnostic support. PLoS One. 2020;15:e0236322. Doi: 10.1371/journal.pone.0236322
31. Hoff J, Wehner W, Nambi V. Troponin in Cardiovascular Disease Prevention: Updates and Future Direction. Curr Atheroscler Rep. 2016;18:12. Doi: 10.1007/s11883-016-0566-5
32. Chmiel C, Reich O, Signorell A, Tandjung R, Rosemann T, Senn O. Appropriateness of diagnostic coronary angiography as a measure of cardiac ischemia testing in non-emergency patients - a retrospective cross-sectional analysis. PLoS One. 2015;10:e0117172. Doi: 10.1371/journal.pone.0117172
33. Rahman H, Corcoran D, Aetesam-Ur-Rahman M, Hoole SP, Berry C, Perera D. Diagnosis of patients with angina and non-obstructive coronary disease in the catheter laboratory. Heart. 2019;105:1536–1542. Doi: 10.1136/heartjnl-2019-315042
34. Brush JE, Jr., Chaudhry SI, Dreyer RP, D'Onofrio G, Greene EJ, Hajduk AM, Lu Y, Krumholz HM. Sex differences in symptom complexity and door-to-balloon time in patients with ST-Elevation Myocardial Infarction. Am J Cardiol. 2023;197:101–107. Doi: 10.1016/j.amjcard.2023.03.009
35. Qureshi AI, Suri MF, Kirmani JF, Divani AA. The relative impact of inadequate primary and secondary prevention on cardiovascular mortality in the United States. Stroke. 2004;35:2346–2350. Doi: 10.1161/01.STR.0000141417.66620.09
36. Kikkert WJ, Hoebers LP, Damman P, Lieve KV, Claessen BE, Vis MM, Baan J, Jr., Koch KT, de Winter RJ, Piek JJ, et al. Recurrent myocardial infarction after primary percutaneous coronary intervention for ST-segment elevation myocardial infarction. Am J Cardiol. 2014;113:229–235. Doi: 10.1016/j.amjcard.2013.08.039
37. McMahon SR, Ades PA, Thompson PD. The role of cardiac rehabilitation in patients with heart disease. Trends Cardiovasc Med. 2017;27:420–425. Doi: 10.1016/j.tcm.2017.02.005
38. Sandesara PB, Lambert CT, Gordon NF, Fletcher GF, Franklin BA, Wenger NK, Sperling L. Cardiac rehabilitation and risk reduction: time to "rebrand and reinvigorate". J Am Coll Cardiol. 2015;65:389–395. Doi: 10.1016/j.jacc.2014.10.059
39. Smith SC, Jr., Allen J, Blair SN, Bonow RO, Brass LM, Fonarow GC, Grundy SM, Hiratzka L, Jones D, Krumholz HM, et al. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update: Endorsed by the National Heart, Lung, and Blood Institute. Circulation. 2006;113:2363–2372. Doi: 10.1161/CIRCULATIONAHA.106.174516
40. Chindhy S, Taub PR, Lavie CJ, Shen J. Current challenges in cardiac rehabilitation: strategies to overcome social factors and attendance barriers. Expert Rev Cardiovasc Ther. 2020;18:777–789. Doi: 10.1080/14779072.2020.1816464
41. Beatty AL, Bradley SM, Maynard C, McCabe JM. Referral to Cardiac rehabilitation after percutaneous coronary intervention, coronary artery bypass surgery, and valve surgery: Data from the Clinical Outcomes Assessment Program. Circ Cardiovasc Qual Outcomes. 2017;10:e003364. Doi: 10.1161/CIRCOUTCOMES.116.003364
42. Parashar S, Spertus JA, Tang F, Bishop KL, Vaccarino V, Jackson CF, Boyden TF, Sperling L. Predictors of early and late enrollment in cardiac rehabilitation, among those referred, after acute myocardial infarction. Circulation. 2012;126:1587–1595. Doi: 10.1161/CIRCULATIONAHA.111.088799
43. Khatib R, Marshall K, Silcock J, Forrest C, Hall AS. Adherence to coronary artery disease secondary prevention medicines: exploring modifiable barriers. Open Heart. 2019;6:e000997. Doi: 10.1136/openhrt-2018-000997
44. Hamilton SJ, Mills B, Birch EM, Thompson SC. Smartphones in the secondary prevention of cardiovascular disease: A systematic review. BMC Cardiovasc Disord. 2018;18:25. Doi: 10.1186/s12872-018-0764-x
45. Paruchuri K, Finneran P, Marston NA, Healy EW, Andreo J, Jr., Lynch R, Blood AJ, Jones-O'Connor M, Lander B, Kelly N, et al. Outcomes of a smartphone-based application with live health-coaching post-percutaneous coronary intervention. EBioMedicine. 2021;72:103593. Doi: 10.1016/j.ebiom.2021.103593
46. Gray R, Indraratna P, Lovell N, Ooi SY. Digital health technology in the prevention of heart failure and coronary artery disease. Cardiovasc Digit Health J. 2022;3:S9–S16. Doi: 10.1016/j.cvdhj.2022.09.002
47. Chen KC, Yin WH, Young MS, Wei J. In-Hospital Tele-ECG Triage and Interventional Cardiologist Activation of the infarct team for STEMI Patients is Associated with improved late clinical outcomes. Acta Cardiol Sin. 2016;32:428–438. Doi: 10.6515/acs20150731c
48. Brunetti ND, Di Pietro G, Aquilino A, Bruno AI, Dellegrottaglie G, Di Giuseppe G, Lopriore C, De Gennaro L, Lanzone S, Caldarola P, et al. Pre-hospital electrocardiogram triage with tele-cardiology support is associated with shorter time-to-balloon and higher rates of timely reperfusion even in rural areas: Data from the Bari- Barletta/Andria/Trani public emergency medical service 118 registry on primary angioplasty in ST-elevation myocardial infarction. Eur Heart J Acute Cardiovasc Care. 2014;3:204–213. Doi: 10.1177/2048872614527009
49. Brunetti ND, De Gennaro L, Correale M, Santoro F, Caldarola P, Gaglione A, Di Biase M. Pre-hospital electrocardiogram triage with telemedicine near halves time to treatment in STEMI: A meta-analysis and meta-regression analysis of non-randomized studies. Int J Cardiol. 2017;232:5–11. Doi: 10.1016/j.ijcard.2017.01.055
50. Cullen L, Collinson PO, Giannitsis E. Point-of-care testing with high-sensitivity cardiac troponin assays: the challenges and opportunities. Emerg Med J. 2022;39:861–866. Doi: 10.1136/emermed-2021-211907
51. Gautam N, Saluja P, Malkawi A, Rabbat MG, Al-Mallah MH, Pontone G, Zhang Y, Lee BC, Al'Aref SJ. Current and Future Applications of Artificial Intelligence in Coronary Artery Disease. Healthcare (Basel). 2022;10:232. Doi: 10.3390/healthcare10020232