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Cost-effectiveness analysis of antithrombotic therapy in nonurgent percutaneous coronary intervention
Kelly M Summers1, David A Holdford, Michael A Crouch
1School of Pharmacy, University of Maryland, Baltimore, USA.
Insights
Bivalirudin with provisional glycoprotein (GP) IIb-IIIa inhibitor therapy is the most cost-effective antithrombotic strategy for nonurgent percutaneous coronary intervention (PCI). This approach is more effective and less expensive than unfractionated heparin (UFH) with routine GP IIb-IIIa inhibitors.
Area of Science:
- Cardiovascular Medicine
- Health Economics
- Interventional Cardiology
Background:
- Nonurgent percutaneous coronary intervention (PCI) requires effective antithrombotic strategies.
- Comparing bivalirudin with provisional glycoprotein (GP) IIb-IIIa inhibitors against unfractionated heparin (UFH) with routine GP IIb-IIIa inhibitors is crucial for optimizing patient outcomes and healthcare costs.
Purpose of the Study:
- To conduct a cost-effectiveness analysis of three antithrombotic strategies during nonurgent PCI.
- To compare bivalirudin with provisional GP IIb-IIIa inhibitor therapy, UFH with eptifibatide, and UFH with abciximab.
Main Methods:
- A literature-based decision model was developed from an institutional perspective.
- Patient data were sourced from the REPLACE-2 trial and three other randomized controlled trials comparing UFH with routine GP IIb-IIIa inhibitors.
Main Results:
- Bivalirudin with provisional GP IIb-IIIa inhibitor therapy dominated the other approaches, being less expensive and more effective.
- UFH with eptifibatide was $74 more expensive and 1.2% less effective; UFH with abciximab was $777 more expensive and 2.3% less effective.
- Sensitivity analyses confirmed robustness but identified thresholds where UFH with eptifibatide became more cost-effective.
Conclusions:
- Bivalirudin with provisional GP IIb-IIIa inhibitor therapy is the most cost-effective antithrombotic strategy for nonurgent PCI.
- Cost-effectiveness is maintained when bivalirudin use and dosing align with REPLACE-2 trial parameters.
Study Objective:
To perform a cost-effectiveness analysis comparing three treatment approaches during nonurgent percutaneous coronary intervention (PCI): bivalirudin with provisional glycoprotein (GP) IIb-IIIa inhibitor therapy, unfractionated heparin (UFH) with eptifibatide, and UFH with abciximab.
Design:
Literature-based decision model from an institutional perspective.
Data Source:
Patient data from the Randomized Evaluation in PCI Linking Angiomax to Reduced Clinical Events (REPLACE)-2 study and three other randomized controlled trials that included UFH and routine GP IIb-IIIa inhibitor (eptifibatide or abciximab) therapy. All included studies were comparable based on patient population, procedural techniques, and general treatment approaches.
Measurements And Main Results:
We included patient populations undergoing contemporary nonurgent PCI to identify probabilities of success or complications (myocardial infarction, urgent revascularization, thrombocytopenia, and major or minor bleeding at 30 days). Costs were assigned to each outcome by incorporating diagnosis-related group-- and/or Current Procedural Terminology--associated costs, institutional drug acquisition costs, and unit replacement costs of platelets and red blood cells. In the base-case analysis, the use of bivalirudin with provisional GP IIb-IIIa inhibitor therapy dominated the UFH and planned GP IIb-IIIa inhibitor approach: UFH with eptifibatide was 74 US dollars more expensive and 1.2% less effective, and UFH with abciximab was 777 US dollars more expensive and 2.3% less effective. Sensitivity analyses indicated that the model results were robust, but also revealed that bivalirudin lost its cost-effectiveness, resulting in UFH with eptifibatide becoming more cost-effective, when two or more vials of bivalirudin were necessary in greater than 27% of cases or when the use of provisional GP IIb-IIIa inhibitor therapy exceeded 20%.
Conclusion:
This analysis indicates that bivalirudin with provisional GP IIb-IIIa inhibitor therapy is the most cost-effective antithrombotic treatment strategy in nonurgent PCI when its use and dosing are consistent with the REPLACE-2 trial.
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