title: Cost effectiveness of left atrial appendage closure with the Watchman device for atrial fibrillation patients with absolute contraindications to warfarin.
abstract: OBJECTIVE
  Atrial fibrillation (AF) patients with contraindications to oral anticoagulation have had few options for stroke prevention. Recently, a novel oral anticoagulant, apixaban, and percutaneous left atrial appendage closure (LAAC) have emerged as safe and effective therapies for stroke risk reduction in these patients. This analysis assessed the cost effectiveness of LAAC with the Watchman device relative to apixaban and aspirin therapy in patients with non-valvular AF and contraindications to warfarin therapy.
  
  
  RESULTS
  A cost-effectiveness model was constructed using data from three studies on stroke prevention in patients with contraindications: the ASAP study evaluating the Watchman device, the ACTIVE A trial of aspirin and clopidogrel, and the AVERROES trial evaluating apixaban. The cost-effectiveness analysis was conducted from a German healthcare payer perspective over a 20-year time horizon. Left atrial appendage closure yielded more quality-adjusted life years (QALYs) than aspirin and apixaban by 2 and 4 years, respectively. At 5 years, LAAC was cost effective compared with aspirin with an incremental cost-effectiveness ratio (ICER) of €16 971. Left atrial appendage closure was cost effective compared with apixaban at 7 years with an ICER of €9040. Left atrial appendage closure was cost saving and more effective than aspirin and apixaban at 8 years and remained so throughout the 20-year time horizon.
  
  
  CONCLUSIONS
  This analysis demonstrates that LAAC with the Watchman device is a cost-effective and cost-saving solution for stroke risk reduction in patients with non-valvular AF who are at risk for stroke but have contraindications to warfarin.
authors.affiliation: Mount Sinai Medical Center, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA vivek.reddy@mountsinai.org.
authors.forename: Vivek Y
authors.initials: VY
authors.lastname: Reddy
authors.affiliation: University of Sheffield, Sheffield, UK.
authors.forename: Ronald L
authors.initials: RL
authors.lastname: Akehurst
authors.affiliation: GfK, Wayland, MA, USA.
authors.forename: Shannon O
authors.initials: SO
authors.lastname: Armstrong
authors.affiliation: Boston Scientific, Marlborough, MA, USA.
authors.forename: Stacey L
authors.initials: SL
authors.lastname: Amorosi
authors.affiliation: BresMed, Sheffield, UK.
authors.forename: Nic
authors.initials: N
authors.lastname: Brereton
authors.affiliation: GfK, Wayland, MA, USA.
authors.forename: Deanna S
authors.initials: DS
authors.lastname: Hertz
authors.affiliation: Mayo Clinic, Rochester, MN, USA.
authors.forename: David R
authors.initials: DR
authors.lastname: Holmes
mesh_terms: D000925:Anticoagulants / Q000627:therapeutic use*; D001241:Aspirin / Q000191:economics* / Q000627:therapeutic use; D020517:Atrial Appendage / Q000601:surgery*; D001281:Atrial Fibrillation / Q000503:physiopathology / Q000628:therapy*; D006348:Cardiac Surgical Procedures / Q000295:instrumentation*; D000077144:Clopidogrel; D000075202:Contraindications; D003362:Cost-Benefit Analysis; D005858:Germany; D006801:Humans; D008390:Markov Chains; D008962:Models, Theoretical; D011720:Pyrazoles / Q000191:economics* / Q000627:therapeutic use; D011728:Pyridones / Q000191:economics* / Q000627:therapeutic use; D011788:Quality of Life; D019057:Quality-Adjusted Life Years; D020521:Stroke / Q000517:prevention & control*; D013988:Ticlopidine / Q000031:analogs & derivatives / Q000627:therapeutic use; D013997:Time Factors; D016896:Treatment Outcome; D014859:Warfarin
chemical_list: D000925:Anticoagulants; D011720:Pyrazoles; D011728:Pyridones; C522181:apixaban; D014859:Warfarin; D000077144:Clopidogrel; D013988:Ticlopidine; D001241:Aspirin
keywords: Apixaban; Contraindicated; Cost-effectiveness analysis; Left atrial appendage closure; Stroke prevention; Watchman
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