Date and Time
November 30, 2011
1:30 PM - 3:00 PM

Availability
Open to the public
No RSVP required

Speaker
Dhruv Kazi, MD

Please note: All research in progress seminars are off-the-record. Any information about methodology and/or results are embargoed until publication.

Background: Platelet inhibition after acute coronary syndrome (ACS) reduces thrombotic events but increases the risk of bleeding. The optimal antiplatelet therapy in this setting is uncertain.

Objective: To determine the most effective and cost-effective strategy for dual antiplatelet therapy after percutaneous coronary intervention (PCI) for ACS.

Design: A Markov model simulated a hypothetical cohort of 100,000 65-year olds undergoing PCI for ACS.

Data Sources: Published clinical trials, Medicare 5% inpatient sample, Nationwide Inpatient Sample, Medicare Expenditure Panel Survey.

Target Population: U.S. adults aged 65 years and older.

Time Horizon: Lifetime.

Perspective: Ideal Insurer.

Interventions: All patients received aspirin plus a second antiplatelet drug for 18 months after PCI.  Five antiplatelet strategies were evaluated: clopidogrel; prasugrel; ticagrelor; genotyping for CYP2C19 polymorphisms followed by clopidogrel in patients without reduced-function polymorphisms, and either ticagrelor (the genotyping–ticagrelor strategy) or prasugrel (genotyping–prasugrel strategy) in patients with reduced-function polymorphisms.

Outcome Measures: Direct medical costs (2009 U.S. dollars), quality-adjusted life years (QALYs).

Results of the Base Case Analysis: Patients receiving clopidogrel accrued $178,169 in medical costs and 9.43 QALYs over their lifetimes. Ticagrelor was the most effective strategy, producing 9.58 QALYs, with an incremental cost-effectiveness ratio of $92,600/QALY relative to the next best strategy, which was genotyping–ticagrelor.

Results of the Sensitivity Analysis: Results were sensitive to modest variations in the efficacy, safety and cost of ticagrelor.

Limitations: No randomized trials have directly compared prasugrel with ticagrelor. Correlations of CYP2C19 polymorphisms with outcomes are retrospective.

Conclusion: Ticagrelor plus aspirin appears to be the optimal strategy for antiplatelet therapy in patients undergoing PCI after ACS, but its cost-effectiveness is sensitive to uncertainties about efficacy, safety and cost of ticagrelor, and the performance of genetic testing.