title: Potential cost-effectiveness of prophylactic use of the implantable cardioverter defibrillator or amiodarone after myocardial infarction.
abstract: 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.
authors.affiliation: Center for Primary Care and Outcomes Research, 179 Encina Commons, Stanford University, Stanford, CA 94305-6019, USA. sanders@stanford.edu
authors.forename: G D
authors.initials: GD
authors.lastname: Sanders
authors.forename: M A
authors.initials: MA
authors.lastname: Hlatky
authors.forename: N R
authors.initials: NR
authors.lastname: Every
authors.forename: K M
authors.initials: KM
authors.lastname: McDonald
authors.forename: P A
authors.initials: PA
authors.lastname: Heidenreich
authors.forename: L S
authors.initials: LS
authors.lastname: Parsons
authors.forename: D K
authors.initials: DK
authors.lastname: Owens
mesh_terms: 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
chemical_list: D000889:Anti-Arrhythmia Agents; D000638:Amiodarone