Filion Kristian B, Xie Xuanqian, van der Avoort Charlotte J, Dendukuri Nandini, Brophy James M
Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, 1020 Pine Avenue West Montreal, Quebec H3A 1A2, Canada.
Int J Technol Assess Health Care. 2009 Apr;25(2):151-60. doi: 10.1017/S0266462309090205. Epub 2009 Mar 31.
Implantable cardioverter defibrillators (ICDs) are an effective but expensive treatment for the prevention of sudden cardiac deaths in patients with severe left-ventricular dysfunction. Recent studies suggest that microvolt T-wave alternans (MTWA) predicts mortality and severe arrhythmic events in this population. However, the impact of MTWA on ICD cost-effectiveness is unknown.
A Markov decision-analysis model evaluated three treatment strategies for primary prevention in patients with severe left-ventricular dysfunction: (i) medical therapy for all; (ii) ICD therapy for all; and (iii) selective ICD therapy based on non-negative (positive or indeterminate) MTWA test results. Incremental cost-effectiveness ratios (ICER) were calculated from the perspective of a third party payer using a 10-year time horizon. Sensitivity analyses examined the robustness of the estimates.
A treatment strategy involving ICD therapy in all patients was associated with an ICER of $121,800/quality-adjusted life-year (QALY) compared with medical therapy, whereas a treatment strategy involving the selective use of ICDs based on MTWA test results was associated with an ICER of $108,900/QALY compared with medical therapy. Sensitivity analyses suggest that, under most scenarios, the selective use of ICDs based on MTWA results does not decrease the ICER to below $100,000/QALY.
MTWA only marginally improves the cost-effectiveness of ICDs for primary prevention in patients with severe left-ventricular dysfunction. There remains a need for improved means to effectively identify which patients will derive the greatest benefit from ICD implantation.
植入式心脏复律除颤器（ICD）是预防严重左心室功能不全患者心源性猝死的一种有效但昂贵的治疗方法。最近的研究表明，微伏级T波交替（MTWA）可预测该人群的死亡率和严重心律失常事件。然而，MTWA对ICD成本效益的影响尚不清楚。
采用马尔可夫决策分析模型评估严重左心室功能不全患者一级预防的三种治疗策略：（i）对所有患者进行药物治疗；（ii）对所有患者进行ICD治疗；（iii）根据MTWA检测结果为非阴性（阳性或不确定）的患者进行选择性ICD治疗。从第三方支付者的角度，采用10年时间范围计算增量成本效益比（ICER）。敏感性分析检验了估计值的稳健性。
与药物治疗相比，对所有患者进行ICD治疗的策略的ICER为121,800美元/质量调整生命年（QALY），而根据MTWA检测结果选择性使用ICD的治疗策略与药物治疗相比，ICER为108,900美元/QALY。敏感性分析表明，在大多数情况下，根据MTWA结果选择性使用ICD不会使ICER降至100,000美元/QALY以下。
MTWA仅在一定程度上提高了ICD对严重左心室功能不全患者一级预防的成本效益。仍需要改进方法，以有效识别哪些患者将从ICD植入中获得最大益处。
