Analyzing the Efficacy and Cost-effectiveness of Anti-platelet Therapy in Unstable Angina/Non-ST Elevation Myocardial Infarction: A Decision Analysis

Abstract

Current pretreatment guidelines for coronary angiography in unstable angina (UA) and non-ST elevation myocardial infarction (NSTEMI) involve the use of dual antiplatelet therapy (DAPT: aspirin + adenosine diphosphate (ADP) P2Y12 inhibitor), whereas the use of triple antiplatelet therapy (TAPT: aspirin + ADP P2Y12 inhibitor + GpIIb/IIIa inhibitor) has limited data due to the increased bleeding risk. However, a study directly comparing the efficacy and cost-effectiveness of DAPT vs. TAPT has not been done. A decision analysis was constructed to determine the ideal pretreatment antiplatelet regimen for UA/NSTEMI patients. The parameters were calculated based on published randomized clinical trials. They consisted of probabilities based on a pretreatment strategy (DAPT, TAPT), interventions (percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), medical management), and 30-day outcomes (no event, bleeding, vascular event, death). A 10,000 run Monte Carlo simulation provided two outputs: estimated life-years extended and costs for each treatment modality. Quality-adjusted life-years (QALYs) were taken into consideration using calculated coefficients from the literature. The cost/QALY ratio was $1,923/QALY for DAPT vs. $4,734/QALY for TAPT. The use of DAPT for pretreatment was favored (2.46 more cost-effective than TAPT). These results will aid clinicians in providing the most clinically sound and fiscally responsible care for UA/NSTEMI patients.