Enoxaparin is a cost-effective adjunct to fibrinolytic therapy for ST-elevation myocardial infarction in contemporary practice.
BACKGROUND
In patients receiving fibrinolytic therapy for ST-elevation myocardial infarction (STEMI), adjunct treatment with enoxaparin has been shown to provide superior net clinical benefit compared with unfractionated heparin (UFH) in the Enoxaparin and Thrombolysis Reperfusion for Acute Myocardial Infarction Treatment - Thrombolysis in Myocardial Infarction (ExTRACT-TIMI) 25 study. The objective of this study was to compare the cost effectiveness of enoxaparin and UFH strategies.


METHODS
A cost-utility analysis was conducted using a two-stage model: (1) A 30-day decision tree analytical model for the acute treatment phase, and (2) a lifetime Markov model (from 30 days post-STEMI until death) populated using patient survival data.


RESULTS
Assuming treatment continuation for 7 days, the mean day 1-30 incremental cost associated with enoxaparin was pound 49 per patient, and mean lifetime incremental cost was pound 592 per patient ( pound 91,091 vs. pound 90,499, respectively). Given an additional 0.048 life years gained per patient with enoxaparin, the cost per life year saved was pound 12,353, and given an additional 0.038 quality-adjusted life years (QALY) per patient with enoxaparin, the cost per QALY was pound 15,413. In an alternative scenario, reflecting contemporary practice assuming early treatment discontinuation at 48 hours, for example following urgent revascularization, the incremental cost per QALY was pound 13,556.


CONCLUSIONS
The use of an enoxaparin versus UFH strategy in patients receiving fibrinolytic therapy for STEMI, whether continued for 7 days or discontinued early, for example following urgent revascularization, is cost effective at a pound 20,000 willingness-to-pay threshold.
Menown
Ian
I
Craigavon Cardiac Centre, Craigavon, Northern Ireland, UK. ian.menown@southerntrust.hscni.net
Montalescot
Gilles
G
Pal
Nikhal
N
Fidler
Carrie
C
Orme
Michelle
M
Gillard
Samantha
S
D003362:Cost-Benefit Analysis; D003663:Decision Trees; D004562:Electrocardiography; D017984:Enoxaparin / Q000191:economics* / Q000627:therapeutic use; D005343:Fibrinolytic Agents / Q000191:economics* / Q000627:therapeutic use; D006493:Heparin / Q000191:economics* / Q000627:therapeutic use; D006801:Humans; D008390:Markov Chains; D009203:Myocardial Infarction / Q000188:drug therapy*; D019057:Quality-Adjusted Life Years
D017984:Enoxaparin; D005343:Fibrinolytic Agents; D006493:Heparin