Key result
Index-admission complete revascularization reduces per-patient MACE by ~0.17 vs. IRA-only PCI while cutting costs.
Why the study?
The cost-effectiveness of complete revascularization at index admission compared with infarct-related artery treatment only in multivessel disease patients undergoing primary PCI for STEMI was uncertain.
Does complete revascularization at index admission improve cost-effectiveness and clinical outcomes compared to IRA-only treatment in patients with multivessel disease undergoing primary PCI for STEMI?
RCT (n=296)
Yes
Does complete revascularization at index admission improve cost-effectiveness and clinical outcomes compared to IRA-only treatment in patients with multivessel disease undergoing primary PCI for STEMI?
Mean Difference: 0.17 (95% CI 0.044–0.296)
Complete revascularization at index admission for STEMI patients with multivessel disease appears to be cost-effective and more clinically effective than IRA-only PCI.
Complete revascularization may dominate IRA-only in cost and MACE reduction; leaves open confirmation in larger contemporary cohorts.
OBJECTIVES: To determine the cost-effectiveness of complete revascularization at index admission compared with infarct-related artery (IRA) treatment only, in patients with multivessel disease undergoing primary percutaneous coronary intervention (P-PCI) for ST-segment elevation myocardial infarction. METHODS: An economic evaluation of a multicenter randomized trial was conducted, comparing complete revascularization at index admission to IRA-only P-PCI in patients with multivessel disease (12-month follow-up). Overall hospital costs (costs for P-PCI procedure(s), hospital length of stay, and any subsequent re-admissions) were estimated. Outcomes were major adverse cardiac events (MACEs, a composite of all-cause death, recurrent myocardial infarction, heart failure, and ischemia-driven revascularization) and quality-adjusted life-years (QALYs) derived from the three-level EuroQol five-dimensional questionnaire. Multiple imputation was undertaken. The mean incremental cost and effect, with associated 95% confidence intervals, the incremental cost-effectiveness ratio, and the cost-effectiveness acceptability curve were estimated. RESULTS: On the basis of 296 patients, the mean incremental overall hospital cost for complete revascularization was estimated to be -£215.96 (-£1390.20 to £958.29), compared with IRA-only, with a per-patient mean reduction in MACEs of 0.170 (0.044 to 0.296) and a QALY gain of 0.011 (-0.019 to 0.041). According to the cost-effectiveness acceptability curve, the probability of complete revascularization being cost-effective was estimated to be 72.0% at a willingness-to-pay threshold value of £20,000 per QALY. CONCLUSIONS: Complete revascularization at index admission was estimated to be more effective (in terms of MACEs and QALYs) and cost-effective (overall costs were estimated to be lower and complete revascularization thereby dominated IRA-only). There was, however, some uncertainty associated with this decision.
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Barton et al. (2017) conducted an RCT in ST-segment elevation myocardial infarction with multivessel disease (n=296). Complete revascularization at index admission vs. Infarct-related artery (IRA) treatment only was evaluated on Major adverse cardiac events (MACEs) (Mean reduction 0.170, 95% CI 0.044-0.296). Complete revascularization at index admission was cost-effective compared to IRA-only PCI, lowering overall costs and reducing per-patient MACEs by a mean of 0.170 (95% CI 0.044-0.296).
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