Implementing a CYP2C19-guided approach for prescribing dual antiplatelet therapy in acute coronary syndrome for patients undergoing percutaneous coronary intervention: a cost-effectiveness analysis

Q: What is the clinical evidence from this study?

Population: Acute coronary syndrome (STEMI and UA/NSTEMI) treated with percutaneous coronary intervention (n=102938). Intervention: CYP2C19-guided dual antiplatelet therapy vs. Current prescribing practice (DAPT with aspirin plus P2Y12 inhibitor without genotype testing). Primary outcome: Incremental cost-effectiveness ratio (ICER) in £ per QALY (ICER £569 per QALY (STEMI); £2,318 per QALY (UA/NSTEMI)).

Q: What does this research mean for the field?

Point-of-care CYP2C19-guided dual antiplatelet therapy is cost-effective compared with current prescribing practice in both STEMI and UA/NSTEMI patients undergoing percutaneous coronary intervention in the NHS. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Alireza Mahboub Ahari; Joe Hilton; Maria Rodrigues; John Henry McDermott; Richard M. Body; Judith Hayward; William G. Newman; Katherine Payne

doi:10.1186/s40360-026-01255-4

October 20, 2026BMC Pharmacology and ToxicologyOpen Access

Implementing a CYP2C19-guided approach for prescribing dual antiplatelet therapy in acute coronary syndrome for patients undergoing percutaneous coronary intervention: a cost-effectiveness analysis

View Full Paper

Ask AI

Bookmark

Share

Key result

CYP2C19-guided DAPT proves cost-effective in ACS, costing ~£569 per QALY gained in STEMI.

ICER £569 per QALY (STEMI); £2,318 per QALY (UA/NSTEMI)
n=102,938

Why the study?

Prescribing guidelines recommend prasugrel or ticagrelor with aspirin after PCI for ACS, but the cost-effectiveness of CYP2C19-guided DAPT prescribing compared with current practice was unknown.

Does point-of-care CYP2C19 genetic testing to guide dual antiplatelet therapy improve cost-effectiveness (QALYs and costs) compared to current prescribing practice in patients with acute coronary syndrome undergoing percutaneous coronary intervention?

Key Points

To evaluate the cost-effectiveness of a point-of-care CYP2C19 genetic test to guide dual antiplatelet therapy (DAPT) prescribing compared with current standard prescribing practice in the NHS in England for patients undergoing PCI for acute coronary syndrome.
A hybrid decision-tree and state transition Markov model with a 40-year lifetime horizon was constructed for two populations: STEMI and UA/NSTEMI.
In the guided strategy, CYP2C19 loss-of-function (LoF) carriers received prasugrel or ticagrelor, while non-LoF carriers received clopidogrel.
Costs were evaluated at 2024/25 prices from an NHS and Social Services perspective, with clinical event rates and utilities sourced from published literature and national registries.
For STEMI, CYP2C19-guided DAPT generated an additional 0.0439 QALYs at an additional cost of £25, resulting in an incremental cost-effectiveness ratio (ICER) of £569 per QALY.
For UA/NSTEMI, the guided strategy yielded an additional 0.0358 QALYs at an incremental cost of £83, yielding an ICER of £2,318 per QALY.
At a cost-effectiveness threshold of £20,000 per QALY, the probability of CYP2C19-guided DAPT being cost-effective was 87.6% for STEMI and 94.3% for UA/NSTEMI.

Structured PICO

Does point-of-care CYP2C19 genetic testing to guide dual antiplatelet therapy improve cost-effectiveness (QALYs and costs) compared to current prescribing practice in patients with acute coronary syndrome undergoing percutaneous coronary intervention?

P

Population

102,938 modeled patients in England with acute coronary syndrome undergoing percutaneous coronary intervention, split into STEMI and UA/NSTEMI cohorts, evaluated over a lifetime horizon.

I

Intervention

Point-of-care CYP2C19 genetic testing to guide dual antiplatelet therapy (DAPT) for 12 months. Non-loss-of-function carriers received clopidogrel 75 mg daily plus aspirin; loss-of-function carriers received ticagrelor 90 mg twice daily plus aspirin or prasugrel 5-10 mg daily plus aspirin.

C

Comparator

Current prescribing practice of dual antiplatelet therapy (DAPT) for 12 months, comprising aspirin plus either ticagrelor, prasugrel, or clopidogrel, allocated according to published clinical guidelines and observed NHS prescribing patterns.

O

Outcome

Costs (£, 2024/25 prices) and Quality-Adjusted Life-Years (QALYs) over a lifetime (40-year) horizon, expressed as an Incremental Cost-Effectiveness Ratio (ICER).

Main Result

Effect estimate: ICER £569 per QALY (STEMI); £2,318 per QALY (UA/NSTEMI)

A CYP2C19-guided strategy for dual antiplatelet therapy prescription in ACS patients undergoing PCI is highly cost-effective within the UK NHS, generating health gains at very low incremental costs.

Limitations

Differential treatment effects were only applied during the first 12 months
Oral anticoagulant use was not modeled as a separate subgroup
Uncertainty around the full unit cost of point-of-care testing in NHS pathways
Turnaround time was not explicitly modeled as a separate parameter
Oral anticoagulant use was not modelled as a separate subgroup due to lack of data
Discontinuation of DAPT was not modelled as a separate clinical event
Treatment effects were assumed not to extend beyond the one-year follow-up due to limited availability of robust data on multiple downstream events

Ask about this paper

Answers are grounded in this paper and cite their sources.

Implication

May support CYP2C19-guided DAPT adoption in NHS ACS care; modeling leaves open confirmation by prospective trials.

Abstract

Background Prescribing guidelines recommend prasugrel or ticagrelor with aspirin as dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS), with clopidogrel reserved for people at high bleeding risk or with contraindications. We evaluated the cost-effectiveness of a point-of-care CYP2C19 genetic test to guide prescribing of DAPT compared with current prescribing practice in the Nathinal Health Service (NHS) in England. Methods We designed a hybrid decision-tree and state transition Markov model (40-year horizon) to calculate the costs and Quality-Adjusted Life-Years (QALYs) of CYP2C19-guided DAPT compared with current prescribing for two post-PCI populations: ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction or unstable angina (UA/NSTEMI). In CYP2C19-guided DAPT, loss of function (LoF) carriers were prescribed prasugrel or ticagrelor; non-LoF carriers prescribed clopidogrel. Costs (£, 2024/25 prices, NHS and Social Services), event rates, and utility values were sourced from published data. Sensitivity analyses measured uncertainty in the analysis results. The R programming language implementation of our decision-analytic model is available at https://github.com/JBHilton/pg-ap-analytics and archived at https://doi.org/10.5281/zenodo.20629081 . Results CYP2C19-guided DAPT generated an additional 0.0439 QALYs at an additional cost of £25 for STEMI, giving an incremental cost-effectiveness ratio (ICER) of £569 per QALY. For UA/NSTEMI, CYP2C19-guided DAPT generated an additional 0.0358 QALYs at an additional cost of £83, giving an ICER of £2,318 per QALY. At a cost-effectiveness threshold of £20,000 per QALY, CYP2C19-guided DAPT had a probability of being cost-effective of 87.6% in the STEMI population and 94.3% in the UA/NSTEMI population. Conclusions CYP2C19-guided DAPT is likely to be a cost-effective use of the NHS budget when compared with current prescribing practice for both STEMI and UA/NSTEMI populations.

Discussion

No takes yet. Share an insight, caveat, or question.

Cite This Study

Ahari et al. (2026) studied Acute coronary syndrome (STEMI and UA/NSTEMI) treated with percutaneous coronary intervention (n=102,938). CYP2C19-guided dual antiplatelet therapy vs. Current prescribing practice (DAPT with aspirin plus P2Y12 inhibitor without genotype testing) was evaluated on Incremental cost-effectiveness ratio (ICER) in £ per QALY (ICER £569 per QALY (STEMI); £2,318 per QALY (UA/NSTEMI)). CYP2C19-guided DAPT generated additional QALYs at an incremental cost of £569 per QALY for STEMI and £2,318 per QALY for UA/NSTEMI, proving cost-effective compared to current prescribing practice.

synapsesocial.com/papers/6ad8a1e74fe90d57c1329a32 https://doi.org/10.1186/s40360-026-01255-4

View Full Paper

Ask AI

Bookmark

Share

Implementing a CYP2C19-guided approach for prescribing dual antiplatelet therapy in acute coronary syndrome for patients undergoing percutaneous coronary intervention: a cost-effectiveness analysis

Key Points

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Implementing a CYP2C19-guided approach for prescribing dual antiplatelet therapy in acute coronary syndrome for patients undergoing percutaneous coronary intervention: a cost-effectiveness analysis

Key Points

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Keep reading

Keep reading