Yaron Arbel1, Maria C Bennell2, Shaun G Goodman3, Harindra C Wijeysundera4. 1. Department of Cardiology, Tel Aviv Medical Center, Tel Aviv, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. 2. Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. 3. St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada. 4. Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada. Electronic address: Harindra.Wijeysundera@sunnybrook.ca.
Abstract
BACKGROUND: There is uncertainty regarding the optimal duration of dual-antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI). Our goal was to evaluate the cost-effectiveness of different durations of DAPT. METHODS: We created a probabilistic patient-level Markov microsimulation model to assess the discounted lifetime costs and quality-adjusted life years (QALYs) of short duration (3-6 months: short-duration group) vs standard therapy (12 months: standard-duration group) vs prolonged therapy (30-36 months: long-duration group) in patients undergoing PCI. RESULTS: The majority of patients in the model underwent PCI for stable angina (47.1%) with second-generation drug-eluting stents (62%) and were receiving clopidogrel (83.6%). Short-duration DAPT was the most effective strategy (7.163 ± 1.098 QALYs) compared with standard-duration DAPT (7.161 ± 1.097 QALYs) and long-duration DAPT (7.156 ± 1.097 QALYs). However, the magnitude of these differences was very small. Similarly, the average discounted lifetime cost was CAN$24,859 ± $6533 for short duration, $25,045 ± $6533 for standard duration, and $25,046 ± $6548 for long duration. Thus, in the base-case analysis, short duration was dominant, being more effective and less expensive. However, there was a moderate degree of uncertainty, because short duration was the preferred option in only ∼ 55% of simulations at a willingness to pay threshold of $50,000. CONCLUSIONS: Based on a stable angina cohort receiving clopidogrel with second-generation stents, a short duration of DAPT was marginally better. However, the differences are minimal, and decisions about duration of therapy should be driven by clinical data, patient risk of adverse events, including bleeding, and cardiovascular events.
BACKGROUND: There is uncertainty regarding the optimal duration of dual-antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI). Our goal was to evaluate the cost-effectiveness of different durations of DAPT. METHODS: We created a probabilistic patient-level Markov microsimulation model to assess the discounted lifetime costs and quality-adjusted life years (QALYs) of short duration (3-6 months: short-duration group) vs standard therapy (12 months: standard-duration group) vs prolonged therapy (30-36 months: long-duration group) in patients undergoing PCI. RESULTS: The majority of patients in the model underwent PCI for stable angina (47.1%) with second-generation drug-eluting stents (62%) and were receiving clopidogrel (83.6%). Short-duration DAPT was the most effective strategy (7.163 ± 1.098 QALYs) compared with standard-duration DAPT (7.161 ± 1.097 QALYs) and long-duration DAPT (7.156 ± 1.097 QALYs). However, the magnitude of these differences was very small. Similarly, the average discounted lifetime cost was CAN$24,859 ± $6533 for short duration, $25,045 ± $6533 for standard duration, and $25,046 ± $6548 for long duration. Thus, in the base-case analysis, short duration was dominant, being more effective and less expensive. However, there was a moderate degree of uncertainty, because short duration was the preferred option in only ∼ 55% of simulations at a willingness to pay threshold of $50,000. CONCLUSIONS: Based on a stable angina cohort receiving clopidogrel with second-generation stents, a short duration of DAPT was marginally better. However, the differences are minimal, and decisions about duration of therapy should be driven by clinical data, patient risk of adverse events, including bleeding, and cardiovascular events.