title: Cost-effectiveness of pharmacologic and invasive therapies for stroke prophylaxis in atrial fibrillation.
abstract: Atrial fibrillation is an abnormal heart rhythm characterized by rapid, disorganized activation (fibrillation) of the left and right atria of the heart, and is responsible for 15% of 700,000 strokes in the United States each year. There are multiple pharmacologic and nonpharmacologic therapies used for stroke prevention in atrial fibrillation, including vitamin K antagonists such as warfarin, antiplatelet agents such as aspirin and clopidogrel, and newer agents such as dabigatran, rivaroxaban and apixaban. Nonpharmacologic therapies involve excluding the left atrial appendage from the systemic circulation by surgical ligation or excision, percutaneous ligation, or endovascular implantation of a left atrial occlusion device. Because atrial fibrillation-related stroke is preventable, a comparison of the value of these interventions by cost-effectiveness analysis (CEA) could inform clinical and health policy recommendations. In this article, we review the principles of CEA and identify 11 articles that examine CEA of stroke prophylaxis strategies in atrial fibrillation. Although most studies evaluate aspirin and warfarin across a variety of atrial fibrillation stroke risk profiles, we also review new literature on new pharmacologic therapies such as direct thrombin inhibitors and discuss the potential value of device-based therapies.
authors.affiliation: Veterans Affairs Palo Alto Healthcare System, Palo Alto, California 94304, USA.
authors.forename: Matthew D
authors.initials: MD
authors.lastname: Solomon
authors.forename: Aditya J
authors.initials: AJ
authors.lastname: Ullal
authors.forename: Donald D
authors.initials: DD
authors.lastname: Hoang
authors.forename: James V
authors.initials: JV
authors.lastname: Freeman
authors.forename: Paul
authors.initials: P
authors.lastname: Heidenreich
authors.forename: Mintu P
authors.initials: MP
authors.lastname: Turakhia
mesh_terms: D000925:Anticoagulants / Q000009:adverse effects / Q000191:economics; D020517:Atrial Appendage / Q000601:surgery; D001281:Atrial Fibrillation / Q000150:complications / Q000191:economics* / Q000628:therapy*; D006328:Cardiac Catheterization / Q000191:economics / Q000295:instrumentation; D006348:Cardiac Surgical Procedures / Q000191:economics; D003362:Cost-Benefit Analysis; D016527:Drug Costs; D017048:Health Care Costs; D006470:Hemorrhage / Q000139:chemically induced / Q000191:economics; D006801:Humans; D011314:Preventive Health Services / Q000191:economics*; D055989:Septal Occluder Device / Q000191:economics; D020521:Stroke / Q000191:economics* / Q000209:etiology / Q000517:prevention & control*; D016896:Treatment Outcome
chemical_list: D000925:Anticoagulants