Understanding the cost-effectiveness of bivalirudin

While unfractionated heparin (UFH) + glycoprotein IIB/IIIA inhibitors (GPI) have been considered the ‘gold standard’ for preventing ischaemic complications during percutaneous coronary intervention (PCI), the quest for a safer (with respect to complications from bleeding) and equally effective (with respect to complications from ischaemia) anticoagulant led to the development of the direct thrombin inhibitor, bivalirudin. Bivalirudin has been tested in pivotal randomised trials1–7 of patients with stable angina, acute coronary syndrome (ACS) and ST-segment elevation myocardial infarction (STEMI). In these trials, bivalirudin consistently reduced complications from bleeding, with no difference in ischaemic events.1–7 In the HORIZONS-AMI trial of 3602 patients with STEMI who were undergoing primary PCI,2 ,3 bivalirudin was also associated with a 1.1% reduction in 30-day mortality,2 which was sustained at 1 and 3 years.3 Given these advantages, but the high costs of drug acquisition, the cost-effectiveness of bivalirudin have been of great interest to payers and hospitals. Prior economic evaluations of bivalirudin relative to UFH + GPI in the setting of non-emergent PCI (REPLACE-2) and ACS (ACUITY), from the US healthcare system, have demonstrated cost savings associated with bivalirudin.8 ,9 A cost-effective model from the UK perspective, that used data inputs from the ACUITY trial, also found bivalirudin to be cost effective (though not cost saving).10 However, until the present study10a no economic evaluation of bivalirudin in patients with STEMI undergoing primary PCI has appeared in the literature. In this edition of Heart , Schwenkglenks et al 10a present a model-based cost-effectiveness analysis from the UK perspective of bivalirudin versus UFH + GPI for patients with STEMI, who were undergoing primary PCI, based on results from HORIZONS-AMI. Using …