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) undergoing percutaneous coronary intervention (PCI) (n=102938). Intervention: Point-of-care CYP2C19 genetic testing to guide dual antiplatelet therapy (CYP2C19-guided DAPT) vs. Current standard prescribing practice of DAPT (aspirin 75-150 mg daily plus ticagrelor, prasugrel, or clopidogrel for 12 months). Primary outcome: Incremental cost-effectiveness ratio (ICER, £ per QALY gained) and Quality-Adjusted Life-Years (QALYs) in the STEMI cohort (ICER £569 per QALY (+0.0439 QALYs at +£25 cost) in STEMI; ICER £2,318 per QALY (+0.0358 QALYs at +£83 cost) in 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 patients undergoing percutaneous coronary intervention for acute coronary syndrome 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

Point-of-care CYP2C19-guided DAPT is highly cost-effective after PCI for ACS, costing ~£569 per QALY.

ICER £+569 per QALY (+0.0439 QALYs at +£25 cost) in STEMI; ICER £2,318 per QALY (+0.0358 QALYs at +£83 cost) in UA/NSTEMI
n=102,938

Why the study?

Prescribing guidelines recommend prasugrel or ticagrelor over clopidogrel as DAPT after PCI for ACS, motivating an evaluation of the cost-effectiveness of point-of-care CYP2C19 genetic testing to guide DAPT compared with current prescribing practice in the NHS in England.

Does point-of-care CYP2C19-guided dual antiplatelet therapy improve quality-adjusted life-years and prove cost-effective compared to standard prescribing practice in patients with acute coronary syndrome undergoing percutaneous coronary intervention?

Key Points

To assess the cost-effectiveness of point-of-care CYP2C19 genetic testing to guide dual antiplatelet therapy prescribing compared with current practice in acute coronary syndrome patients undergoing percutaneous coronary intervention.
Constructed a hybrid decision-tree and state transition Markov model over a 40-year time horizon using UK NHS and Social Services perspectives at 2024/25 prices.
Evaluated two post-percutaneous coronary intervention cohorts: ST-segment elevation myocardial infarction (STEMI; n=41,690) and unstable angina or non-ST-segment elevation myocardial infarction (UA/NSTEMI; n=61,248).
Modelled CYP2C19-guided therapy where loss-of-function allele carriers received prasugrel or ticagrelor and non-carriers received clopidogrel, assessing outcomes against a £20,000 per QALY willingness-to-pay threshold.
In the STEMI cohort, CYP2C19-guided therapy gained 0.0439 additional QALYs at an added cost of £25 per patient, yielding an incremental cost-effectiveness ratio of £569 per QALY.
In the UA/NSTEMI cohort, guided therapy gained 0.0358 additional QALYs at an added cost of £83 per patient, resulting in an incremental cost-effectiveness ratio of £2,318 per QALY.
At a £20,000 per QALY threshold, CYP2C19-guided therapy demonstrated a probability of being cost-effective of 87.6% in the STEMI population and 94.3% in the UA/NSTEMI population.

Structured PICO

Does point-of-care CYP2C19-guided dual antiplatelet therapy improve quality-adjusted life-years and prove cost-effective compared to standard prescribing practice in patients with acute coronary syndrome undergoing percutaneous coronary intervention?

P

Population

102,938 modelled patients in England with acute coronary syndrome (41,690 STEMI and 61,248 UA/NSTEMI) undergoing PCI and eligible for 12-month DAPT, evaluated over a 40-year lifetime horizon.

I

Intervention

Point-of-care CYP2C19 genetic testing (GeneDrive platform using buccal swab) to guide dual antiplatelet therapy (DAPT) prescribing for 12 months: non-loss-of-function (LoF) carriers (normal, rapid, or ultra-rapid metabolisers) received clopidogrel 75 mg once daily (loading dose 300 to 600 mg) plus aspirin 75 to 150 mg once daily; LoF carriers (intermediate or poor metabolisers) received ticagrelor 90 mg twice daily (loading dose 180 mg) or prasugrel 5 to 10 mg once daily (loading dose 60 mg) plus aspirin 75 to 150 mg once daily.

C

Comparator

Current prescribing practice (standard care) for 12 months, defined as dual antiplatelet therapy with aspirin 75 to 150 mg once daily plus one P2Y12 inhibitor chosen by the treating cardiologist according to clinical guidelines: ticagrelor 90 mg twice daily (loading dose 180 mg), prasugrel 5 to 10 mg once daily (loading dose 60 mg), or clopidogrel 75 mg once daily (loading dose 300 to 600 mg).

O

Outcome

Incremental cost-effectiveness ratio (ICER, £ per Quality-Adjusted Life-Year [QALY] gained), expected lifetime healthcare costs (£, 2024/25 prices), life-years, QALYs, and incremental net monetary benefit (NMB) over a 40-year lifetime horizon (discounted at 3.5% per annum).

Main Result

Mean Difference: 0.0439

Absolute Event Rate: 6.345% vs 6.301%

Point-of-care CYP2C19-guided dual antiplatelet therapy following PCI for both STEMI and UA/NSTEMI is highly cost-effective within the English NHS budget compared to standard unguided prescribing.

Limitations

Simplified assumption that treatment effects did not extend beyond the one-year follow-up as all individuals were considered to continue aspirin monotherapy, reflecting limited availability of robust data on multiple downstream events.
Adverse events (bleeding and dyspnoea) were treated as first-year acute consequences only and were not carried forward into the long-term Markov phase.
Individuals were assumed to experience only one clinical event in the first year post-PCI.

Implication

May support NHS adoption of CYP2C19-guided DAPT post-PCI; leaves open need for prospective outcome 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 NHS in England (NHS). 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, 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 model was built in R (available on GitHub). 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. In 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 was 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) undergoing percutaneous coronary intervention (PCI) (n=102,938). Point-of-care CYP2C19 genetic testing to guide dual antiplatelet therapy (CYP2C19-guided DAPT) vs. Current standard prescribing practice of DAPT (aspirin 75-150 mg daily plus ticagrelor, prasugrel, or clopidogrel for 12 months) was evaluated on Incremental cost-effectiveness ratio (ICER, £ per QALY gained) and Quality-Adjusted Life-Years (QALYs) in the STEMI cohort (ICER £569 per QALY (+0.0439 QALYs at +£25 cost) in STEMI; ICER £2,318 per QALY (+0.0358 QALYs at +£83 cost) in UA/NSTEMI). Point-of-care CYP2C19-guided DAPT was cost-effective in post-PCI ACS patients, yielding an ICER of £569/QALY in STEMI (+0.0439 QALYs) and £2,318/QALY in UA/NSTEMI (+0.0358 QALYs).

synapsesocial.com/papers/6ae28dedcbadf70daf6c3f1d 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

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

Implication

Abstract

Discussion

Cite This Study

Keep reading

Keep reading