Catherwood E, Fitzpatrick W D, Greenberg M L, Holzberger P T, Malenka D J, Gerling B R, Birkmeyer J D
Cardiology Division, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire 03756-0001, USA.
Ann Intern Med. 1999 Apr 20;130(8):625-36. doi: 10.7326/0003-4819-130-8-199904200-00002.
Physicians managing patients with nonvalvular atrial fibrillation must consider the risks, benefits, and costs of treatments designed to restore and maintain sinus rhythm compared with those of rate control with antithrombotic prophylaxis.
To compare the cost-effectiveness of cardioversion, with or without antiarrhythmic agents, with that of rate control plus warfarin or aspirin.
A Markov decision-analytic model was designed to simulate long-term health and economic outcomes.
Published literature and hospital accounting information.
Hypothetical cohort of 70-year-old patients with different baseline risks for stroke.
3 months.
Societal.
Therapeutic strategies using different combinations of cardioversion alone, cardioversion plus amiodarone or quinidine therapy, and rate control with antithrombotic treatment.
Expected costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness.
RESULTS OF BASE-CASE ANALYSIS: Strategies involving cardioversion alone were more effective and less costly than those not involving this option. For patients at high risk for ischemic stroke (5.3% per year), cardioversion alone followed by repeated cardioversion plus amiodarone therapy on relapse was most cost-effective ($9300 per QALY) compared with cardioversion alone followed by warfarin therapy on relapse. This strategy was also preferred for the moderate-risk cohort (3.6% per year), but the benefit was more expensive ($18,900 per QALY). In the lowest-risk cohort (1.6% per year), cardioversion alone followed by aspirin therapy on relapse was optimal.
The choice of optimal strategy and incremental cost-effectiveness was substantially influenced by the baseline risk for stroke, rate of stroke in sinus rhythm, efficacy of warfarin, and costs and utilities for long-term warfarin and amiodarone therapy.
Cardioversion alone should be the initial management strategy for persistent nonvalvular atrial fibrillation. On relapse of arrhythmia, repeated cardioversion plus low-dose amiodarone is cost-effective for patients at moderate to high risk for ischemic stroke.
与采用抗血栓预防的心率控制相比，治疗非瓣膜性心房颤动患者的医生必须考虑旨在恢复和维持窦性心律的治疗的风险、益处和成本。
比较采用或不采用抗心律失常药物进行心脏复律与心率控制加华法林或阿司匹林的成本效益。
设计了一个马尔可夫决策分析模型来模拟长期健康和经济结果。
已发表的文献和医院会计信息。
假设的70岁中风基线风险不同的患者队列。
3个月。
社会视角。
单独使用心脏复律、心脏复律加胺碘酮或奎尼丁治疗以及抗血栓治疗的心率控制的不同组合的治疗策略。
预期成本、质量调整生命年（QALYs）和增量成本效益。
单独进行心脏复律的策略比不涉及该选项的策略更有效且成本更低。对于缺血性中风高危患者（每年5.3%），与复发时单独进行心脏复律然后使用华法林治疗相比，单独进行心脏复律然后复发时重复进行心脏复律加胺碘酮治疗最具成本效益（每QALY 9300美元）。该策略对中度风险队列（每年3.6%）也更有利，但效益成本更高（每QALY 18900美元）。在最低风险队列（每年1.6%）中，单独进行心脏复律然后复发时使用阿司匹林治疗是最佳选择。
最佳策略的选择和增量成本效益受到中风基线风险、窦性心律时的中风发生率、华法林的疗效以及长期华法林和胺碘酮治疗的成本和效用的显著影响。
单独进行心脏复律应作为持续性非瓣膜性心房颤动的初始管理策略。对于缺血性中风中度至高度风险的患者，心律失常复发时重复进行心脏复律加小剂量胺碘酮具有成本效益。
