Potential cost-effectiveness of prophylactic use of the implantable cardioverter defibrillator or amiodarone after myocardial infarction.
BACKGROUND
Clinical trials have shown that implantable cardioverter defibrillators (ICDs) improve survival in patients with sustained ventricular arrhythmias.


OBJECTIVE
To determine the efficacy necessary to make prophylactic ICD or amiodarone therapy cost-effective in patients with myocardial infarction.


METHODS
Markov model-based cost utility analysis.


METHODS
Survival, cardiac death, and inpatient costs were estimated on the basis of the Myocardial Infarction Triage and Intervention registry. Other data were derived from the literature.


METHODS
Patients with past myocardial infarction who did not have sustained ventricular arrhythmia.


METHODS
Lifetime.


CONCLUSIONS
Societal.


METHODS
ICD or amiodarone compared with no treatment.


METHODS
Life-years, quality-adjusted life-years (QALYs), costs, number needed to treat, and incremental cost-effectiveness.


RESULTS
Compared with no treatment, ICD use led to the greatest QALYs and the highest expenditures. Amiodarone use resulted in intermediate QALYs and costs. To obtain acceptable cost-effectiveness thresholds (</=$75,000/QALY), ICDs had to reduce arrhythmic death by 50% and amiodarone had to reduce total death by 7% in patients with depressed ejection fraction.


RESULTS
For moderate efficacies, in patients with ejection fractions less than or equal to 0.3, 0.31 to 0.4, and greater than 0.4, the cost-effectiveness of amiodarone compared with no therapy was $43,100/QALY, $66,500/QALY, and $132,500/QALY, respectively, and the cost-effectiveness of ICD compared with amiodarone was $71,800/QALY, $195,700/QALY, and $557,900/QALY, respectively.


CONCLUSIONS
Use of ICD or amiodarone in patients with past myocardial infarction and severely depressed left ventricular function may provide substantial clinical benefit at an acceptable cost. These results highlight the importance of clinical trials of ICDs in patients with low ejection fractions who have had myocardial infarction.
Sanders
G D
GD
Center for Primary Care and Outcomes Research, 179 Encina Commons, Stanford University, Stanford, CA 94305-6019, USA. sanders@stanford.edu
Hlatky
M A
MA
Every
N R
NR
McDonald
K M
KM
Heidenreich
P A
PA
Parsons
L S
LS
Owens
D K
DK
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000638:Amiodarone / Q000191:economics* / Q000627:therapeutic use; D000889:Anti-Arrhythmia Agents / Q000191:economics* / Q000627:therapeutic use; D001145:Arrhythmias, Cardiac / Q000209:etiology / Q000517:prevention & control*; D003362:Cost-Benefit Analysis; D016757:Death, Sudden, Cardiac / Q000517:prevention & control*; D003663:Decision Trees; D017147:Defibrillators, Implantable / Q000191:economics*; D005260:Female; D017721:Hospital Costs; D006801:Humans; D008297:Male; D008390:Markov Chains; D008875:Middle Aged; D009203:Myocardial Infarction / Q000150:complications / Q000503:physiopathology / Q000517:prevention & control*; D019057:Quality-Adjusted Life Years; D012008:Recurrence; D012680:Sensitivity and Specificity; D013318:Stroke Volume; D018487:Ventricular Dysfunction, Left / Q000503:physiopathology
D000889:Anti-Arrhythmia Agents; D000638:Amiodarone