Sabe-se que tanto o uso de stens quanto a terapia anticoagulante com abciximab têm efeitos benéficos na evolução de pacientes vítimas de infarto agudo do miocárdio (IAM). Para avaliar os custos e os benefícios dessas duas estratégias, investigadores do ensaio CADILLAC (Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications) realizaram um estudo prospectivo, publicado na revista Circulation esta semana. Os autores concluíram que o stent apresenta ótima relação custo-benefício, ao passo que o mesmo só poderá ser dito do abciximab após a verificação de ganhos na sobrevida dos pacientes.
Circulation
(Circulation. 2003;108:2857.)
© 2003 American Heart Association, Inc.
Clinical Investigation and Reports |
Cost-Effectiveness of Coronary Stenting and Abciximab for Patients With Acute Myocardial Infarction
Results From the CADILLAC (Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications) Trial
Ameet Bakhai, MD, MRCP; Gregg W. Stone, MD; Cindy L. Grines, MD; Sabina A. Murphy, MPH; Louise Githiora, BA; Ronna H. Berezin, MPH; David A. Cox, MD; Thomas Stuckey, MD; John J. Griffin, MD; James E. Tcheng, MD; David J. Cohen, MD, MSc, for the CADILLAC Investigators
From the Harvard Clinical Research Institute (A.B., S.A.M., L.G., R.H.B., D.J.C.), the Division of Cardiology, Beth Israel-Deaconess Medical Center, Boston, Mass (A.B., D.J.C.); the Clinical Trials and Evaluation Unit, Royal Brompton Hospital, London, UK (A.B.); Lenox Hill Hospital, New York, NY (G.W.S.); William Beaumont Hospital, Royal Oak, Mich (C.L.G.); Mid-Carolina Cardiology, Charlotte, NC (D.A.C.); Moses Cone Memorial Hospital, Greensboro, NC (T.S.); Virginia Beach General Hospital, Virginia Beach, Va (J.J.G.); and Duke University, Durham, NC (J.E.T.).
Correspondence to David J. Cohen, MD, Cardiovascular Division, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215. E-mail dcohen@caregroup.harvard.edu
Received August 8, 2003; revision received September 23, 2003; accepted September 25, 2003.
Background— Both stenting and the glycoprotein IIb/IIIa inhibitor abciximab improve outcomes for patients undergoing primary angioplasty for acute myocardial infarction (AMI). However, the cost-effectiveness of these strategies is unknown.
Methods and Results— We performed a prospective cost-utility analysis among US participants in the CADILLAC trial. Patients with AMI (n=1703) were randomized to stenting versus balloon angioplasty (PTCA) and abciximab versus no abciximab according to a 2-by-2 factorial design. Total 1-year costs and lifetime incremental cost-effectiveness ratios, measured as cost per quality-adjusted year of life (QALY) gained, were calculated. Compared with PTCA, stenting increased procedural costs by $1148 and initial hospital costs by $1384 (both P<0.001). By 1-year, stenting led to fewer repeat revascularization procedures and reduced follow-up medical care costs by $1215, such that aggregate costs were similar for the PTCA and stent groups ($18 690 versus $18 859, P=0.75). The cost-effectiveness ratio for stenting versus PTCA was favorable at $11 237/QALY gained and remained <$20 000/QALY in sensitivity analyses. Compared with standard anticoagulation, abciximab increased initial procedural costs by $1122 (P<0.001). By facilitating accelerated hospital discharge, abciximab reduced length of stay by 
0.6 days, offsetting most of the drug costs. These cost offsets were not maintained, however; aggregate 1-year costs for the abciximab group were $1244 greater than for standard therapy ($19 389 versus $18 145, P=0.02). Abciximab was reasonably cost-effective (cost-effectiveness ratio $21 305/QALY) only if nonsignificant differences in 1-year mortality (3.7% versus 4.3%, P=0.62) were incorporated in the analysis.
Conclusions— Primary stenting is a highly cost-effective treatment for AMI. The cost-effectiveness of abciximab in this setting is uncertain and depends primarily on whether long-term survival is enhanced.
Key Words: angioplasty • myocardial infarction • stents • cost-benefit analysis
