Cost-Effectiveness of Long-Term Ticagrelor in Patients With Prior Myocardial Infarction
Key result
Long-term ticagrelor plus aspirin costs ~$95,000 per QALY gained vs aspirin alone after MI.
- 95% CI 7441-7930
- P<0.001
- n=21,162
Why the study?
In patients with MI 1 to 3 years earlier, ticagrelor plus low-dose aspirin reduces cardiovascular events but increases major bleeding, prompting an evaluation of its cost-effectiveness.
Key Points
- To assess the lifetime cost-effectiveness and economic value of extended ticagrelor therapy compared with standard care in patients with a history of myocardial infarction.
- Decision-analytic Markov modeling evaluating long-term ticagrelor therapy versus aspirin monotherapy in post-myocardial infarction patients over a lifetime horizon.
- Model inputs included cardiovascular event rates, bleeding risks, quality-adjusted life years (QALYs), and healthcare costs from healthcare payer perspectives.
- Extended ticagrelor therapy produced incremental gains in quality-adjusted life years while reducing lifetime incidences of recurrent myocardial infarction, stroke, and cardiovascular death.
- The incremental cost-effectiveness ratio for long-term ticagrelor remained within widely accepted willingness-to-pay thresholds per QALY gained.
Study Design
Type
RCT (n=21,162)
Randomization
randomized
PICO
P
Population
21,162 patients with a myocardial infarction within the prior 3 years, followed for a median of 33 months.
I
Intervention / Comparator
Ticagrelor + low-dose aspirin vs ASA alone (60 mg twice daily + low-dose ASA)
O
Primary Outcome
Total costs (7441-7930), p=<0.001
Main Result
Absolute Event Rate: 10016% vs 2333%
p-value: p=<0.001
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Our recent research shows that prolonged treatment with a 60mg twice-daily dose of ticagrelor beyond this first year provides effective protection against further heart attack or stroke, albeit with an increase in risk of bleeding. The provisional approval by NICE for a longer course of treatment opens the way to a new option for managing risk in patients who are at higher risk of further heart attack.”
CLCarole LongsonDirector, Centre for Health Technology Evaluation, NICE
“Despite the availability of effective secondary prevention treatments as many as a quarter of people who have had a heart attack go on to have another heart attack or stroke – often with devastating consequences. Fear of a recurrence can have a significant negative impact on a person's quality of life. The evidence shows that ticagrelor, in combination with aspirin, is effective at reducing the risk of further heart attacks and strokes in people who have already had a heart attack.”
Implication
Supports extended ticagrelor in post-MI secondary prevention; extends RCT efficacy data with lifetime cost-effectiveness modeling.
Abstract
BACKGROUND: In patients with a myocardial infarction (MI) 1 to 3 years earlier, treatment with ticagrelor + low-dose aspirin (ASA) reduces the risk of cardiovascular (CV) death, MI, or stroke compared with low-dose aspirin alone, but at an increased risk of major bleeding. OBJECTIVES: The authors evaluated cost-effectiveness of ticagrelor + low-dose ASA in patients with prior MI within the prior 3 years. METHODS: The authors performed a prospective economic substudy alongside the PEGASUS-TIMI 54 (Prevention of Cardiovascular Events in Patients With Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin-Thrombolysis In Myocardial Infarction 54) trial, which randomized 21,162 patients to ASA alone, ticagrelor 60 mg twice daily + low-dose ASA, or ticagrelor 90 mg twice daily + low-dose ASA. Medical resource use data were collected over a median 33-month follow-up. Costs were assessed from the U.S. health care system perspective. In-trial data relating to survival, utility, and costs were combined with lifetime projections to evaluate lifetime cost-effectiveness of the Food and Drug Administration-approved lower-dose ticagrelor regimen (60 mg twice daily). RESULTS: Hospitalization costs were similar for ticagrelor 60 mg and placebo ($2,262 vs. $2,333; 95% confidence interval for difference -$303 to $163; p = 0.54); after inclusion of a daily ticagrelor 60 mg cost of $10.52, total costs were higher for ticagrelor ($10,016 vs. $2,333; 95% CI: $7,441 to $7,930; p < 0.001). In-trial quality-adjusted life-years (QALYs) were similar (2.28 vs. 2.27; p = 0.34). Over a lifetime horizon, ticagrelor was associated with QALY gains of 0.078 and incremental costs of $7,435, yielding an incremental cost-effectiveness ratio (ICER) of $94,917/QALY gained. Several high-risk groups had more favorable ICERs, including patients with >1 prior MI, multivessel disease, diabetes, renal dysfunction (all with ICERs $50,000 to $70,000/QALY gained), patients age <75 years (ICER = $44,779/QALY gained), and patients with peripheral artery disease (ICER = $13,427/QALY gained). CONCLUSIONS: For patients with a history of MI >1 year previously, long-term treatment with ticagrelor 60 mg + low-dose ASA yields a cost-effectiveness ratio suggesting intermediate value based on current guidelines. Ticagrelor appears to provide higher value for patients in several recognized high-risk subgroups. (Prevention of Cardiovascular Events [e.g., Death From Heart or Vascular Disease, Heart Attack, or Stroke] in Patients With Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin [PEGASUS]; NCT01225562).
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Cite This Study
Magnuson et al. (2017) conducted an RCT in Prior myocardial infarction (n=21,162). Ticagrelor + low-dose aspirin vs. ASA alone was evaluated on Total costs (95% CI 7441-7930, p=<0.001). Long-term treatment with ticagrelor 60 mg plus low-dose aspirin yielded an incremental cost-effectiveness ratio of $94,917/QALY gained compared to aspirin alone in patients with prior MI.