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Using triple antiplatelet therapy in patients with non-ST elevation acute coronary syndrome managed invasively: a
Jaime Latour-Pérez1, Eva de Miguel Balsa, Lourdes Betegón
1Intensive Care Unit, Hospital General Universitario de Elche, Elche, Spain. jlatour@wanadoo.es
Insights
Routine upstream use of glycoprotein IIb/IIIa (GPIIb/IIIa) inhibitors is cost-effective for high-risk non-ST elevation acute coronary syndrome (NSTE-ACS) patients. This strategy offers value, especially in younger individuals with intermediate to high TIMI scores.
Area of Science:
- Cardiovascular Medicine
- Health Economics
- Interventional Cardiology
Background:
- Non-ST elevation acute coronary syndrome (NSTE-ACS) management involves complex treatment decisions.
- Glycoprotein IIb/IIIa (GPIIb/IIIa) inhibitors are used in acute coronary syndromes but their cost-effectiveness requires evaluation.
- Optimal timing and patient selection for GPIIb/IIIa inhibitors in NSTE-ACS with dual antiplatelet therapy remain areas of investigation.
Purpose of the Study:
- To determine the incremental cost-effectiveness ratio (ICER) of GPIIb/IIIa inhibitors in NSTE-ACS patients.
- To compare routine upstream versus deferred selective use of GPIIb/IIIa inhibitors against no GPIIb/IIIa inhibitor therapy.
- To assess cost-effectiveness from a healthcare system perspective over a patient's lifespan.
Main Methods:
- Cost-effectiveness and cost-utility analyses were conducted using a Markov model.
- Patient risk was stratified using the Thrombolysis in Myocardial Infarction (TIMI) risk score.
- Univariate sensitivity analysis and probabilistic microsimulation were employed to assess robustness.
Main Results:
- Routine upstream GPIIb/IIIa inhibitor use (Strategy A) was the most effective strategy.
- The ICER for Strategy A was 15,150 euros per quality-adjusted life-year gained in the base case.
- Cost-effectiveness of Strategy A was highly sensitive to patient age and TIMI risk score, being most favorable in younger, higher-risk patients.
Conclusions:
- Upstream GPIIb/IIIa inhibitor use is cost-effective in high-risk NSTE-ACS patients (TIMI score ≥3) on aspirin and clopidogrel.
- This strategy demonstrates particular value in younger patient cohorts.
- Deferred selective use of GPIIb/IIIa inhibitors was dominated by other strategies.
Objectives:
To assess the incremental cost-effectiveness ratio (ICER) of glycoprotein IIb/IIIa (GPIIb/IIIa) inhibitors in patients with non-ST elevation acute coronary syndrome (NSTE-ACS) pretreated with aspirin and clopidogrel undergoing an early invasive treatment strategy.
Methods:
Cost-effectiveness analysis and cost-utility analysis were performed from a health-care system perspective, based on a Markov model with a time horizon of the patient life span. The risk of death and ischemic events was assessed using the Thrombolysis in Myocardial Infarction (TIMI) risk score. We compared three strategies: 1) routine upstream use of a GPIIb/IIIa inhibitor to all patients before angiography, 2) deferred selective use of abciximab in the catheterization laboratory just before angioplasty, and 3) double antiplatelet therapy without GPIIb/IIIa inhibitors. Both univariate sensitivity analysis and second-order probabilistic microsimulation were performed.
Results:
In the base case (65 years old, TIMI score 3), strategy A was the most effective, with an ICER of 15,150 euros per quality-adjusted life-year gained. Strategy B was dominated by a combination of strategies A and C. The ICER was very sensitive to the age and baseline risk of the patient. According to the widely accepted cost-effectiveness thresholds, strategy A would be cost-effective only in patients with an intermediate to high TIMI score, especially within the younger age groups. The probability that strategy A was cost-effective under the base case was 91.2%.
Conclusions:
The use of GPIIb/IIIa inhibitors upstream in high-risk NSTE-ACS patients (TIMI score > or = 3) pretreated with aspirin and clopidogrel is cost-effective, particularly in the younger age groups.
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