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Adding a second antiplatelet agent to aspirin is more effective than aspirin alone in preventing repeat vascular events in acute coronary syndrome (ACS) patients. We sought to determine the cost-effectiveness of universal or phenotype-driven selection of dual antiplatelet treatment (DAPT) in ACS.
A hybrid decision tree/Markov model was used to calculate 5-year costs (in 2011 US$), quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs) of 1-year of universal (given to all patients) or phenotype-driven (given only to patients with high platelet reactivity denoted by a value >230 on the VerifyNow P2Y12 assay, Accumetrics, San Diego, California, others received generic clopidogrel) ticagrelor or prasugrel compared to universal generic clopidogrel. We assumed a cohort of 65-year-old ACS patients, a 32% incidence of high platelet reactivity at the time of the index event and a 13% incidence at 1-month. The analysis was conducted from a US payer perspective and used a 1-year cycle length. Data depicting the efficacy and safety of DAPT were taken from multinational randomized trials.
The phenotype-driven ticagrelor and prasugrel strategies were cost-effective compared to universal clopidogrel (ICERs=$40,100 and $49,143/QALY); however, universal ticagrelor and prasugrel strategies were not (ICERs=$61,651 and $96,261/QALY). The model's conclusions were most sensitive to differences in antiplatelet agent costs and drug-specific relative risks of death. The model was also sensitive to time horizon, with ICERs for phenotype-driven strategies falling below $50,000/QALY as early as 3 years after the index event. Monte Carlo simulation suggested phenotype-driven ticagrelor, phenotype-driven prasugrel, universal ticagrelor and universal prasugrel would have ICERs<$50,000/QALY in 52%, 40%, 23%, and 2% of 10,000 iterations vs. universal clopidogrel.
Even in the age of generic clopidogrel, phenotype-driven selection of new antiplatelet agents appears to be a cost-effective strategy in ACS patients compared to universal clopidogrel.
West, Room 3001
Saturday, March 09, 2013, 9:15 a.m.-9:30 a.m.
Session Title: ACS: New Agents and Approaches
Abstract Category: 3. Acute Coronary Syndromes: Therapy
Presentation Number: 901-8
- 2013 American College of Cardiology Foundation