title: Using triple antiplatelet therapy in patients with non-ST elevation acute coronary syndrome managed invasively: a cost-effectiveness analysis.
abstract: OBJECTIVE
  To assess the incremental cost-effectiveness ratio (ICER) of glycoprotein IIb/IIIa (GPIIb/IIIa) inhibitors in patients with non-ST elevation acute coronary syndrome (NSTE-ACS) pretreated with aspirin and clopidogrel undergoing an early invasive treatment strategy.
  
  
  METHODS
  Cost-effectiveness analysis and cost-utility analysis were performed from a health-care system perspective, based on a Markov model with a time horizon of the patient life span. The risk of death and ischemic events was assessed using the Thrombolysis in Myocardial Infarction (TIMI) risk score. We compared three strategies: 1) routine upstream use of a GPIIb/IIIa inhibitor to all patients before angiography, 2) deferred selective use of abciximab in the catheterization laboratory just before angioplasty, and 3) double antiplatelet therapy without GPIIb/IIIa inhibitors. Both univariate sensitivity analysis and second-order probabilistic microsimulation were performed.
  
  
  RESULTS
  In the base case (65 years old, TIMI score 3), strategy A was the most effective, with an ICER of 15,150 euros per quality-adjusted life-year gained. Strategy B was dominated by a combination of strategies A and C. The ICER was very sensitive to the age and baseline risk of the patient. According to the widely accepted cost-effectiveness thresholds, strategy A would be cost-effective only in patients with an intermediate to high TIMI score, especially within the younger age groups. The probability that strategy A was cost-effective under the base case was 91.2%.
  
  
  CONCLUSIONS
  The use of GPIIb/IIIa inhibitors upstream in high-risk NSTE-ACS patients (TIMI score > or = 3) pretreated with aspirin and clopidogrel is cost-effective, particularly in the younger age groups.
authors.affiliation: Intensive Care Unit, Hospital General Universitario de Elche, Elche, Spain. jlatour@wanadoo.es
authors.forename: Jaime
authors.initials: J
authors.lastname: Latour-Pérez
authors.forename: Eva
authors.initials: E
authors.lastname: de Miguel Balsa
authors.forename: Lourdes
authors.initials: L
authors.lastname: Betegón
authors.forename: Xavier
authors.initials: X
authors.lastname: Badia
mesh_terms: D054058:Acute Coronary Syndrome / Q000188:drug therapy* / Q000191:economics; D000368:Aged; D001241:Aspirin / Q000191:economics* / Q000627:therapeutic use; D000077144:Clopidogrel; D016001:Confidence Intervals; D003362:Cost-Benefit Analysis; D004359:Drug Therapy, Combination; D005260:Female; D006801:Humans; D008297:Male; D008390:Markov Chains; D018803:Models, Economic; D010975:Platelet Aggregation Inhibitors / Q000191:economics* / Q000627:therapeutic use; D019039:Platelet Glycoprotein GPIIb-IIIa Complex / Q000037:antagonists & inhibitors*; D019057:Quality-Adjusted Life Years; D012306:Risk; D018570:Risk Assessment; D013030:Spain; D013988:Ticlopidine / Q000031:analogs & derivatives* / Q000191:economics / Q000627:therapeutic use
chemical_list: D010975:Platelet Aggregation Inhibitors; D019039:Platelet Glycoprotein GPIIb-IIIa Complex; D000077144:Clopidogrel; D013988:Ticlopidine; D001241:Aspirin