Department of Medicine, Washington University School of Medicine, Campus Box 8005, 660 S. Euclid Ave, St. Louis, MO 63110, USA.
Circulation. 2011 Jun 7;123(22):2562-70. doi: 10.1161/CIRCULATIONAHA.110.985655. Epub 2011 May 23.
Recent studies have investigated alternatives to warfarin for stroke prophylaxis in patients with atrial fibrillation (AF), but whether these alternatives are cost-effective is unknown.
On the basis of the results from Randomized Evaluation of Long Term Anticoagulation Therapy (RE-LY) and other trials, we developed a decision-analysis model to compare the cost and quality-adjusted survival of various antithrombotic therapies. We ran our Markov model in a hypothetical cohort of 70-year-old patients with AF using a cost-effectiveness threshold of $50 000/quality-adjusted life-year. We estimated the cost of dabigatran as US $9 a day. For a patient with an average risk of major hemorrhage (≈3%/y), the most cost-effective therapy depended on stroke risk. For patients with the lowest stroke rate (CHADS2 stroke score of 0), only aspirin was cost-effective. For patients with a moderate stroke rate (CHADS2 score of 1 or 2), warfarin was cost-effective unless the risk of hemorrhage was high or quality of international normalized ratio control was poor (time in the therapeutic range <57.1%). For patients with a high stroke risk (CHADS(2) stroke score ≥3), dabigatran 150 mg (twice daily) was cost-effective unless international normalized ratio control was excellent (time in the therapeutic range >72.6%). Neither dabigatran 110 mg nor dual therapy (aspirin and clopidogrel) was cost-effective.
Dabigatran 150 mg (twice daily) was cost-effective in AF populations at high risk of hemorrhage or high risk of stroke unless international normalized ratio control with warfarin was excellent. Warfarin was cost-effective in moderate-risk AF populations unless international normalized ratio control was poor.
最近的研究调查了房颤（AF）患者中风预防的华法林替代药物，但这些替代药物是否具有成本效益尚不清楚。
基于随机评估长期抗凝治疗（RE-LY）和其他试验的结果，我们开发了一种决策分析模型，以比较各种抗血栓治疗的成本和质量调整生存。我们在一个假设的 70 岁 AF 患者队列中使用成本效益阈值为 50000 美元/质量调整生命年来运行我们的马尔可夫模型。我们估计达比加群的成本为每天 9 美元。对于平均大出血风险（≈3%/年）的患者，最具成本效益的治疗方法取决于中风风险。对于中风率最低的患者（CHADS2 中风评分 0），只有阿司匹林具有成本效益。对于中风率中等的患者（CHADS2 评分 1 或 2），除非出血风险高或国际标准化比值控制质量差（治疗范围时间<57.1%），否则华法林具有成本效益。对于中风风险高的患者（CHADS2 中风评分≥3），达比加群 150mg（每日两次）具有成本效益，除非国际标准化比值控制非常好（治疗范围时间>72.6%）。达比加群 110mg 或双联治疗（阿司匹林和氯吡格雷）均不具有成本效益。
达比加群 150mg（每日两次）在出血风险高或中风风险高的 AF 患者中具有成本效益，除非华法林的国际标准化比值控制非常好。在中度风险的 AF 患者中，华法林具有成本效益，除非国际标准化比值控制不佳。
