title: Time to Cost-Effectiveness Following Stroke Reduction Strategies in AF: Warfarin Versus NOACs Versus LAA Closure.
abstract: BACKGROUND
  Left atrial appendage closure (LAAC) and nonwarfarin oral anticoagulants (NOACs) have emerged as safe and effective alternatives to warfarin for stroke prophylaxis in patients with nonvalvular atrial fibrillation (AF).
  
  
  OBJECTIVE
  This analysis assessed the cost-effectiveness of warfarin, NOACs, and LAAC with the Watchman device (Boston Scientific, Marlborough, Massachusetts) for stroke risk reduction in patients with nonvalvular AF at multiple time points over a lifetime horizon.
  
  
  METHODS
  A Markov model was developed to assess the cost-effectiveness of LAAC, NOACs, and warfarin from the perspective of the Centers for Medicare & Medicaid Services over a lifetime (20-year) horizon. Patients were 70 years of age and at moderate risk for stroke and bleeding. Clinical event rates, stroke outcomes, and quality of life information were drawn predominantly from PROTECT AF (Watchman Left Atrial Appendage System for Embolic Protection in Patients with Atrial Fibrillation) 4-year data and meta-analyses of warfarin and NOACs. Costs for stroke risk reduction therapies, treatment of associated acute events, and long-term care following disabling stroke were presented in 2015 U.S. dollars.
  
  
  RESULTS
  Relative to warfarin, LAAC was cost-effective at 7 years ($42,994/quality-adjusted life-years [QALY]), and NOACs were cost-effective at 16 years ($48,446/QALY). LAAC was dominant over NOACs by year 5 and warfarin by year 10. At 10 years, LAAC provided more QALYs than warfarin and NOACs (5.855 vs. 5.601 vs. 5.751, respectively). In sensitivity analyses, LAAC remained cost-effective relative to warfarin ($41,470/QALY at 11 years) and NOACs ($21,964/QALY at 10 years), even if procedure costs were doubled.
  
  
  CONCLUSIONS
  Both NOACs and LAAC with the Watchman device were cost-effective relative to warfarin, but LAAC was also found to be cost-effective and to offer better value relative to NOACs. The results of this analysis should be considered when formulating policy and practice guidelines for stroke prevention in AF.
authors.affiliation: Mount Sinai Medical Center, New York, New York. Electronic address: Vivek.Reddy@mountsinai.org.
authors.forename: Vivek Y
authors.initials: VY
authors.lastname: Reddy
authors.affiliation: University of Sheffield, Sheffield, United Kingdom.
authors.forename: Ronald L
authors.initials: RL
authors.lastname: Akehurst
authors.affiliation: GfK, Wayland, Massachusetts.
authors.forename: Shannon O
authors.initials: SO
authors.lastname: Armstrong
authors.affiliation: Boston Scientific, Marlborough, Massachusetts.
authors.forename: Stacey L
authors.initials: SL
authors.lastname: Amorosi
authors.affiliation: BresMed, Sheffield, United Kingdom.
authors.forename: Stephen M
authors.initials: SM
authors.lastname: Beard
authors.affiliation: Mayo Clinic, Rochester, Minnesota.
authors.forename: David R
authors.initials: DR
authors.lastname: Holmes
mesh_terms: D000925:Anticoagulants / Q000627:therapeutic use; D020517:Atrial Appendage; D001281:Atrial Fibrillation / Q000150:complications / Q000628:therapy*; D006348:Cardiac Surgical Procedures / Q000191:economics* / Q000379:methods*; D003362:Cost-Benefit Analysis; D005500:Follow-Up Studies; D005544:Forecasting; D017048:Health Care Costs; D008404:Massachusetts; D017410:Practice Guidelines as Topic; D020521:Stroke / Q000209:etiology / Q000517:prevention & control*; D013997:Time Factors; D014859:Warfarin / Q000627:therapeutic use*
chemical_list: D000925:Anticoagulants; D014859:Warfarin
keywords: Watchman; apixaban; dabigatran; edoxaban; quality of life; rivaroxaban