Cost-effectiveness of antithrombotic therapies for peripheral arterial disease

Antithrombotic treatment plays a critical role in managing peripheral arterial disease and reducing the risk of major adverse limb events and major adverse cardiovascular events after revascularization. Dual antiplatelet therapy (DAPT) with aspirin and clopidogrel is the most commonly used regimen following lower extremity revascularization (LER), but emerging studies suggest that dual antithrombotic pathway inhibition (DPI), which combines a factor Xa inhibitor with an antiplatelet agent, may offer enhanced protection. This study evaluates the clinical outcomes and cost-effectiveness of DPI compared with DAPT in patients undergoing LER.

A retrospective analysis compared the characteristics of patients treated with DAPT and DPI after LER at Yale New Haven Hospital. After applying a 4:1 propensity score matching to adjust for differences in baseline characteristics, the outcomes of the two groups were compared. Cost-effectiveness was evaluated over a 5-year horizon using modeled costs and quality-adjusted life years (QALYs), and the incremental cost-effectiveness ratio was calculated. The willingness-to-pay (WTP) threshold was set at $150,000 per QALY, which aligns with the average U.S. WTP for health interventions.

A total of 986 patients undergoing LER were reviewed, with 5.6% on DPI. After propensity matching (N = 275), Kaplan-Meier analysis showed significantly improved major adverse limb event-free survival in the DPI group, with no difference in adverse cardiovascular event-free survival between the two groups. Although the DPI strategy incurred higher costs ($73,826 vs $39,548), it yielded greater health benefits (4.64 vs 3.51 QALYs). The incremental cost-effectiveness ratio was $30,331 per QALY, well below the U.S. WTP threshold of $150,000 per QALY, indicating that DPI is a cost-effective alternative compared with DAPT.

DPI is associated with improved limb-related outcomes and represents a cost-effective alternative to DAPT for antithrombotic therapy after LER.