Cost-effectiveness of cardiac resynchronization therapy in patients with asymptomatic to mild heart failure: insights from the European cohort of the REVERSE (Resynchronization Reverses remodeling in Systolic Left Ventricular Dysfunction).
OBJECTIVE
To assess the cost-effectiveness of cardiac resynchronization therapy (CRT) compared with optimal medical therapy in patients with New York Heart Association (NYHA) II heart failure (HF) or NYHA I with previous HF symptoms.


RESULTS
A proportion in state model with Monte Carlo simulation was developed to assess the costs, life years and quality-adjusted life year (QALYs) associated with CRT-ON and -OFF over a 10 year time period. Data from 262 patients in the European cohort of the REVERSE clinical trial (QRS ≥ 120 ms, left ventricular ejection fraction ≤ 40%, CRT-ON, n = 180, CRT-OFF, n = 82) were used to model all-cause mortality, change in NYHA class and resource use. EQ-5D preference weights were taken from a previous cost-effectiveness model of CRT and unit costs from national UK databases. Costs and benefits were discounted at 3.5% p.a. Extensive deterministic and probabilistic sensitivity analyses were performed. Compared with CRT-OFF, 0.94 life years or 0.80 QALYs were gained in the CRT ON group at an additional cost of €11 455, yielding an incremental cost-effectiveness ratio of €14.278 per quality-adjusted life year (QALY) gained. At a threshold of €33 000 (£30 000) per QALY gained, the probability that CRT is cost-effective is 79.6%. Cardiac resynchronization therapy becomes cost effective after ∼4.5 years. Cardiac resynchronization therapy needs only to demonstrate a modest impact on all cause mortality (hazard ratio = 0.82) in order to demonstrate cost-effectiveness. The results are robust to changes in all other parameters.


CONCLUSIONS
Cardiac resynchronization therapy is a cost-effective intervention for patients with mildly symptomatic HF and for asymptomatic patients with left ventricular dysfunction and previous HF symptoms.
Department of Cardiology, Karolina University Hospital, Stockholm, Sweden.
Cecilia
C
Linde
Stuart
S
Mealing
Neil
N
Hawkins
James
J
Eaton
Ben
B
Brown
Jean-Claude
JC
Daubert
D000368:Aged; D058406:Cardiac Resynchronization Therapy / Q000191:economics* / Q000379:methods; D003362:Cost-Benefit Analysis; D017147:Defibrillators, Implantable / Q000191:economics*; D004311:Double-Blind Method; D006333:Heart Failure / Q000191:economics / Q000628:therapy*; D006760:Hospitalization / Q000191:economics; D006801:Humans; D008875:Middle Aged; D011446:Prospective Studies; D019057:Quality-Adjusted Life Years; D016896:Treatment Outcome; D018487:Ventricular Dysfunction, Left / Q000191:economics / Q000628:therapy*; D020257:Ventricular Remodeling / Q000502:physiology