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ORONARY COMPUTED TOMOgraphic (CT) angiography is a noninvasive test that enables direct visualization of coronary artery disease (CAD) and correlates favorably with invasive coronary angiography (ICA) for measures of stenosis severity. 1 However, CT cannot determine the hemodynamic significance of CAD, and even among CTidentified obstructive stenoses confirmed by ICA, fewer than half are ischemia-causing. 2,3 These findings underscore an unreliable relationship of stenosis severity to ischemia and have raised concerns that use of CT may pre-cipitate unnecessary ICA and coronary revascularization for patients who do not have ischemia. 4,5 These concerns stem from recent randomized trials that have identified no survival benefit for patients who undergo angiographically based coronary revascularization. 6,7 As an ad-junct to ICA, fractional flow reserve (FFR) has served as a useful tool to determine the likelihood that a coronary For editorial comment see p 1269.

Patients treated with percutaneous repair more commonly required surgery for residual MR during the first year after treatment, but between 1- and 5-year follow-up, comparably low rates of surgery for MV dysfunction with either percutaneous or surgical therapy endorse the durability of MR reduction with both repair techniques. (EVEREST II Pivotal Study High Risk Registry; NCT00209274).

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BackgroundBoth supervised exercise (SE) and stenting (ST) improve functional status, symptoms, and quality of life compared with optimal medical care (OMC) in patients with claudication. The relative cost‐effectiveness of these strategies is not well defined.Methods and ResultsThe Claudication: Exercise Versus Endoluminal Revascularization (CLEVER) study randomized patients with claudication due to aortoiliac stenosis to a 6‐month SE program, to ST, or to OMC. Participants who completed 6‐month follow‐up (n=98) were included in a health economic analysis through 18 months. Costs were assessed using resource‐based methods and hospital billing data. Quality‐adjusted life‐years were estimated using the EQ‐5D. Markov modeling based on the in‐trial results was used to explore the impact of assumptions about the longer term durability of observed differences in quality of life. Through 18 months, mean healthcare costs were $5178, $9804, and $14 590 per patient for OMC, SE, and ST, respectively. Measured quality‐adjusted life‐years through 18 months were 1.04, 1.16, and 1.20. In our base case analysis, which assumed that observed differences in quality of life would dissipate after 5 years, the incremental cost‐effectiveness ratios were $24 070 per quality‐adjusted life‐year gained for SE versus OMC, $41 376 for ST versus OMC, and $122 600 for ST versus SE. If the treatment effect of ST was assumed to be more durable than that of SE, the incremental cost‐effectiveness ratio for ST versus SE became more favorable.ConclusionsBoth SE and ST are economically attractive by US standards relative to OMC for the treatment of claudication in patients with aortoiliac disease. ST is more expensive than SE, with uncertain incremental benefit.Clinical Trial RegistrationURL: www.clinicaltrials.gov, Unique identifier: NCT00132743.