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Multi-vessel coronary artery disease (MVD) in patients presenting with ST-segment elevation myocardial infarction (STEMI) is associated with poor outcomes. Percutaneous coronary intervention (PCI) of all lesions (complete) as compared with culprit lesion only appears to result in improved long-term outcomes based on recent randomized controlled trial data and meta-analyses. Our objective is to evaluate the cost-utility of complete versus culprit-vessel only PCI strategy.
Based on a systematic review and meta-analyses of the literature involving 10 RCTs, a model was developed to simulate costs and quality-adjusted life years (QALYs). In the first 12 months, a decision tree framework was used to define different cardiovascular outcomes for STEMI patients receiving either complete or culprit vessel revascularisation. Cost of comparative treatments and follow-up in relation to cardiovascular events were calculated from the UK National health service perspective.
Higher procedural costs for complete revascularisation were offset by lower costs for repeat revascularisation, myocardial infarction and angina compared to culprit only patients. An ICER of £6,842 indicates a cost-effective strategy with results that were robust for different variations in the input variables.
In this cost-utility analysis comparing complete versus culprit only revascularisation in STEMI patients with multi-vessel disease complete revascularisation is likely to be cost-effective. This analysis is based upon modern day NHS costs, quality of life utility data collected and relevant to primary PCI and outcome probabilities based on 9 RCTS comparing complete versus culprit revascularisation and is therefore the most reliable and complete analysis performed to date.
OTHER: Cost-Effectiveness and Reimbursement Issues