title: The role of risk stratification in the decision to provide upstream versus selective glycoprotein IIb/IIIa inhibitors for acute coronary syndromes: a cost-effectiveness analysis.
abstract: OBJECTIVE
  We endeavored to determine under what conditions a strategy of upstream use of small molecule platelet glycoprotein (GP) IIb/IIIa inhibitors for all acute coronary syndromes (ACS) patients is cost effective compared to that of selective use of abciximab in only those patients requiring percutaneous coronary intervention (PCI).
  
  
  BACKGROUND
  Small molecule GP IIb/IIIa inhibitors have shown benefit in ACS, but abciximab, the more expensive GP IIb/IIIa inhibitor, may be more effective during PCI. However, abciximab does not have proven efficacy in medical management. No prior study has attempted to balance these competing benefits.
  
  
  METHODS
  A decision analysis was performed to examine two strategies: 1) treat all ACS patients upstream with a small molecule GP IIb/IIIa inhibitor and continue through medical management and PCI, if performed; or 2) wait, and selectively use abciximab only in patients who ultimately undergo PCI. Applicable randomized controlled trial data were used for the principal analysis.
  
  
  RESULTS
  The strategy of upstream use of a small molecule GP IIb/IIIa inhibitor was superior to selective use, and economically acceptable, with a cost-effectiveness ratio of 18,000 dollars per year of life gained. The superiority of the upstream use strategy persisted over the majority of sensitivity analyses. When stratified by risk according to Thrombolysis in Myocardial Infarction risk score, a strategy of upstream use was only cost effective in those patients with moderate or high risk.
  
  
  CONCLUSIONS
  Upstream use of small molecule GP IIb/IIIa inhibition in ACS patients with moderate or high risk for cardiovascular events is a cost-effective approach that should be considered in this subset of patients.
authors.affiliation: Division of Cardiovascular Medicine, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA. ruchira.glaser@uphs.upenn.edu
authors.forename: Ruchira
authors.initials: R
authors.lastname: Glaser
authors.forename: Henry A
authors.initials: HA
authors.lastname: Glick
authors.forename: Howard C
authors.initials: HC
authors.lastname: Herrmann
authors.forename: Stephen E
authors.initials: SE
authors.lastname: Kimmel
mesh_terms: D000077284:Abciximab; D000789:Angina, Unstable / Q000188:drug therapy* / Q000191:economics / Q000628:therapy; D015906:Angioplasty, Balloon, Coronary; D000911:Antibodies, Monoclonal / Q000008:administration & dosage* / Q000191:economics; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D016527:Drug Costs; D000077542:Eptifibatide; D006801:Humans; D007140:Immunoglobulin Fab Fragments / Q000008:administration & dosage* / Q000191:economics; D008017:Life Expectancy; D009203:Myocardial Infarction / Q000188:drug therapy* / Q000191:economics / Q000628:therapy; D010455:Peptides / Q000008:administration & dosage* / Q000191:economics; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage* / Q000191:economics; D019039:Platelet Glycoprotein GPIIb-IIIa Complex / Q000037:antagonists & inhibitors*; D019057:Quality-Adjusted Life Years; D018570:Risk Assessment; D012307:Risk Factors; D000077466:Tirofiban; D014443:Tyrosine / Q000008:administration & dosage / Q000031:analogs & derivatives* / Q000191:economics
chemical_list: D000911:Antibodies, Monoclonal; D007140:Immunoglobulin Fab Fragments; D010455:Peptides; D010975:Platelet Aggregation Inhibitors; D019039:Platelet Glycoprotein GPIIb-IIIa Complex; D014443:Tyrosine; D000077466:Tirofiban; D000077542:Eptifibatide; D000077284:Abciximab