Cost-Effectiveness in Patients Undergoing Revascularization of Chronic Total Occluded Coronary Arteries-A Cohort
Emil Nielsen Holck1,2, Naja Stausholm Winther1,2, Lone Juul Hune Mogensen1,2
1Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.
Insights
Successful revascularization of chronic total occluded coronary arteries (CTO) through percutaneous coronary intervention (PCI) is more cost-effective. This approach offers better net benefit for patients compared to incomplete revascularization, though further trials are needed.
Area of Science:
- Cardiovascular Medicine
- Health Economics
- Interventional Cardiology
Background:
- Revascularization for symptomatic chronic total occluded coronary arteries (CTO) is clinically recommended.
- Percutaneous coronary intervention (PCI) is a common treatment modality for CTO.
- The cost-effectiveness of successful CTO revascularization requires further investigation.
Purpose of the Study:
- To evaluate the cost-effectiveness of successful versus unsuccessful PCI for CTO.
- To determine the net benefit and cost-effectiveness planes of CTO revascularization.
- To compare patient outcomes and healthcare costs associated with CTO treatment strategies.
Main Methods:
- A cohort study design was employed, enrolling patients undergoing PCI for CTO.
- Data on major adverse cardio- and cerebrovascular events (MACCE) and cardiac admissions were collected.
- Cost-effectiveness was assessed using net benefit (NB) at 3 years, considering procedure and admission costs versus MACCE and symptomatic events.
Main Results:
- A total of 441 patients with CTO underwent PCI between 2009 and 2019, with a 3-year follow-up.
- Successful revascularization (n=342) resulted in lower mean total costs (EUR 11,719) compared to unsuccessful attempts (n=99, EUR 13,565).
- Successful CTO revascularization demonstrated a positive net benefit (EUR 1,846) for MACCE, with cost-effectiveness planes favoring this approach.
Conclusions:
- Full revascularization of all CTO lesions via PCI is a more cost-efficient treatment strategy.
- The findings suggest improved economic outcomes with successful CTO treatment.
- Randomized controlled trials are recommended to confirm these results and mitigate potential residual confounding.
Background:
Revascularization of patients with chronic total occluded coronary arteries (CTO) is recommended if they have symptoms despite medical treatment. The cost-effectiveness of treatment with percutaneous coronary intervention (PCI) was investigated in this cohort study.
Materials And Methods:
The study was designed as a cohort study enrolling all patients undergoing PCI for a CTO in the Central Region of Denmark and recorded in the EUROCTO database. Major adverse cardio- and cerebrovascular events (MACCE) and admissions for cardiac symptoms were collected in the Western Denmark Heart Registry and through medical Journal Audits. Exposure was defined as successful revascularization of all CTO lesions compared with having one or more remaining CTOs after PCI attempt(s). Cost-effectiveness was evaluated as the net benefit (NB) at the patient level 3 years after treatment and through cost-effectiveness planes. The cost was defined as the cumulative cost of the index procedure and admissions due to MACCE and cardiac symptoms. Effectiveness was defined as the difference in MACCE for the primary analysis and the difference in death and symptomatic admissions for the secondary.
Results:
Between 2009 and 2019, 441 patients with ≥ 3 years of follow-up were treated with PCI for at least one CTO lesion (342 in the successful arm and 99 in the unsuccessful arm). The technical success rate was 85.4%. In total, 155 MACCE and 184 symptomatic admissions occurred in the follow-up period. The mean total cost was EUR 11.719 (11.034; 12.406) in the successful group vs. EUR 13.565 (11.899; 15,231) (p = 0.02) in the unsuccessful group. Net-benefit was EUR 1.846 (64; 3,627) after successful revascularization for MACCE. The adjusted analysis found an NB of EUR 1,481 (-118; 3,079). Bootstrap estimates showed cost-effectiveness planes in favor of successful revascularization.
Conclusion:
Patients fully revascularized for all CTO lesions had a more cost-efficient treatment. However, results need confirmation in a randomized controlled trial due to the risk of residual confounding after adjustment.
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