title: Genetic testing in patients with acute coronary syndrome undergoing percutaneous coronary intervention: a cost-effectiveness analysis.
abstract: BACKGROUND
  The CYP2C19 genotype is a predictor of adverse cardiovascular events in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI) treated with clopidogrel.
  
  
  OBJECTIVE
  We aimed to evaluate the cost-effectiveness of a CYP2C19*2 genotype-guided strategy of antiplatelet therapy in ACS patients undergoing PCI, compared with two 'no testing' strategies (empiric clopidogrel or prasugrel).
  
  
  METHODS
  We developed a Markov model to compare three strategies. The model captured adverse cardiovascular events and antiplatelet-related complications. Costs were expressed in 2010 US dollars and estimated using diagnosis-related group codes and Medicare reimbursement rates. The net wholesale price for prasugrel was estimated as $5.45 per day. A generic estimate for clopidogrel of $1.00 per day was used and genetic testing was assumed to cost $500.
  
  
  RESULTS
  Base case analyses demonstrated little difference between treatment strategies. The genetic testing-guided strategy yielded the most QALYs and was the least costly. Over 15 months, total costs were $18 lower with a gain of 0.004 QALY in the genotype-guided strategy compared with empiric clopidogrel, and $899 lower with a gain of 0.0005 QALY compared with empiric prasugrel. The strongest predictor of the preferred strategy was the relative risk of thrombotic events in carriers compared with wild-type individuals treated with clopidogrel. Above a 47% increased risk, a genotype-guided strategy was the dominant strategy. Above a clopidogrel cost of $3.96 per day, genetic testing was no longer dominant but remained cost-effective.
  
  
  CONCLUSIONS
  Among ACS patients undergoing PCI, a genotype-guided strategy yields similar outcomes to empiric approaches to treatment, but is marginally less costly and more effective.
authors.affiliation: Department of Medicine, Division of Cardiovascular Medicine, New York University School of Medicine, New York, NY 10016, USA.
authors.forename: A
authors.initials: A
authors.lastname: Lala
authors.forename: J S
authors.initials: JS
authors.lastname: Berger
authors.forename: G
authors.initials: G
authors.lastname: Sharma
authors.forename: J S
authors.initials: JS
authors.lastname: Hochman
authors.forename: R
authors.initials: R
authors.lastname: Scott Braithwaite
authors.forename: J A
authors.initials: JA
authors.lastname: Ladapo
mesh_terms: D054058:Acute Coronary Syndrome / Q000175:diagnosis / Q000191:economics* / Q000235:genetics / Q000401:mortality / Q000628:therapy*; D001189:Aryl Hydrocarbon Hydroxylases / Q000235:genetics* / Q000378:metabolism; D002561:Cerebrovascular Disorders / Q000209:etiology; D000077144:Clopidogrel; D003198:Computer Simulation; D003362:Cost-Benefit Analysis; D065731:Cytochrome P-450 CYP2C19; D003661:Decision Support Techniques; D018572:Disease-Free Survival; D016527:Drug Costs; D005787:Gene Frequency; D020022:Genetic Predisposition to Disease; D005820:Genetic Testing / Q000191:economics*; D017048:Health Care Costs; D006470:Hemorrhage / Q000209:etiology; D006801:Humans; D007349:Insurance, Health, Reimbursement / Q000191:economics; D053208:Kaplan-Meier Estimate; D008390:Markov Chains; D006278:Medicare / Q000191:economics; D018803:Models, Economic; D009203:Myocardial Infarction / Q000209:etiology; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000191:economics* / Q000401:mortality; D010597:Pharmacogenetics / Q000191:economics; D010641:Phenotype; D010879:Piperazines / Q000191:economics / Q000378:metabolism / Q000627:therapeutic use; D010975:Platelet Aggregation Inhibitors / Q000191:economics / Q000378:metabolism / Q000627:therapeutic use; D000068799:Prasugrel Hydrochloride; D011237:Predictive Value of Tests; D019057:Quality-Adjusted Life Years; D018570:Risk Assessment; D012307:Risk Factors; D013876:Thiophenes / Q000191:economics / Q000378:metabolism / Q000627:therapeutic use; D013927:Thrombosis / Q000191:economics / Q000235:genetics / Q000517:prevention & control; D013988:Ticlopidine / Q000031:analogs & derivatives / Q000191:economics / Q000378:metabolism / Q000627:therapeutic use; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States
chemical_list: D010879:Piperazines; D010975:Platelet Aggregation Inhibitors; D013876:Thiophenes; D000077144:Clopidogrel; D001189:Aryl Hydrocarbon Hydroxylases; C045793:CYP2C19 protein, human; D065731:Cytochrome P-450 CYP2C19; D000068799:Prasugrel Hydrochloride; D013988:Ticlopidine