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Cost-effectiveness of cardioversion and antiarrhythmic therapy in nonvalvular atrial fibrillation
E Catherwood1, W D Fitzpatrick, M L Greenberg
1Cardiology Division, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire 03756-0001, USA.
Insights
Cardioversion alone is the most cost-effective initial strategy for nonvalvular atrial fibrillation. For patients with moderate to high stroke risk, repeated cardioversion with amiodarone is preferred upon relapse.
Area of Science:
- Cardiovascular Medicine
- Health Economics
- Decision Analysis
Background:
- Nonvalvular atrial fibrillation (AF) management requires balancing rhythm control against rate control with antithrombotic prophylaxis.
- Physicians must weigh risks, benefits, and costs of various AF treatment strategies.
Purpose of the Study:
- To compare the cost-effectiveness of cardioversion (with or without antiarrhythmic agents) versus rate control (with warfarin or aspirin) for nonvalvular AF.
- To identify optimal long-term management strategies based on patient risk profiles.
Main Methods:
- A Markov decision-analytic model simulated long-term health and economic outcomes.
- Data sources included published literature and hospital accounting information.
- A hypothetical cohort of 70-year-old patients with varying stroke risks was analyzed over a 3-month time horizon.
Main Results:
- Cardioversion alone was more effective and less costly than strategies not involving it.
- For high-risk patients, initial cardioversion followed by cardioversion plus amiodarone on relapse was most cost-effective ($9300/QALY).
- For moderate-risk patients, this strategy cost $18,900/QALY, while for low-risk patients, cardioversion alone followed by aspirin on relapse was optimal.
Conclusions:
- Cardioversion alone is recommended as the initial management strategy for persistent nonvalvular AF.
- Repeated cardioversion plus low-dose amiodarone is a cost-effective strategy for moderate to high-risk patients upon AF relapse.
Background:
Physicians managing patients with nonvalvular atrial fibrillation must consider the risks, benefits, and costs of treatments designed to restore and maintain sinus rhythm compared with those of rate control with antithrombotic prophylaxis.
Objective:
To compare the cost-effectiveness of cardioversion, with or without antiarrhythmic agents, with that of rate control plus warfarin or aspirin.
Design:
A Markov decision-analytic model was designed to simulate long-term health and economic outcomes.
Data Sources:
Published literature and hospital accounting information.
Target Population:
Hypothetical cohort of 70-year-old patients with different baseline risks for stroke.
Time Horizon:
3 months.
Perspective:
Societal.
Intervention:
Therapeutic strategies using different combinations of cardioversion alone, cardioversion plus amiodarone or quinidine therapy, and rate control with antithrombotic treatment.
Outcome Measures:
Expected costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness.
Results Of Base-Case Analysis:
Strategies involving cardioversion alone were more effective and less costly than those not involving this option. For patients at high risk for ischemic stroke (5.3% per year), cardioversion alone followed by repeated cardioversion plus amiodarone therapy on relapse was most cost-effective ($9300 per QALY) compared with cardioversion alone followed by warfarin therapy on relapse. This strategy was also preferred for the moderate-risk cohort (3.6% per year), but the benefit was more expensive ($18,900 per QALY). In the lowest-risk cohort (1.6% per year), cardioversion alone followed by aspirin therapy on relapse was optimal.
Results Of Sensitivity Analysis:
The choice of optimal strategy and incremental cost-effectiveness was substantially influenced by the baseline risk for stroke, rate of stroke in sinus rhythm, efficacy of warfarin, and costs and utilities for long-term warfarin and amiodarone therapy.
Conclusions:
Cardioversion alone should be the initial management strategy for persistent nonvalvular atrial fibrillation. On relapse of arrhythmia, repeated cardioversion plus low-dose amiodarone is cost-effective for patients at moderate to high risk for ischemic stroke.