Jiang Minghuan, You Joyce H S
School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, N.T, Hong Kong, China.
Clin Cardiol. 2017 Oct;40(10):789-796. doi: 10.1002/clc.22756. Epub 2017 Jul 6.
Continuation of dual antiplatelet therapy (DAPT) beyond 1 year reduces late stent thrombosis and ischemic events after drug-eluting stents (DES) but increases risk of bleeding. We hypothesized that extending DAPT from 12 months to 30 months in patients with acute coronary syndrome (ACS) after DES is cost-effective. A lifelong decision-analytic model was designed to simulate 2 antiplatelet strategies in event-free ACS patients who had completed 12-month DAPT after DES: aspirin monotherapy (75-162 mg daily) and continuation of DAPT (clopidogrel 75 mg daily plus aspirin 75-162 mg daily) for 18 months. Clinical event rates, direct medical costs, and quality-adjusted life-years (QALYs) gained were the primary outcomes from the US healthcare provider perspective. Base-case results showed DAPT continuation gained higher QALYs (8.1769 vs 8.1582 QALYs) at lower cost (USD42 982 vs USD44 063). One-way sensitivity analysis found that base-case QALYs were sensitive to odds ratio (OR) of cardiovascular death with DAPT continuation and base-case cost was sensitive to OR of nonfatal stroke with DAPT continuation. DAPT continuation remained cost-effective when the ORs of nonfatal stroke and cardiovascular death were below 1.241 and 1.188, respectively. In probabilistic sensitivity analysis, DAPT continuation was the preferred strategy in 74.75% of 10 000 Monte Carlo simulations at willingness-to-pay threshold of 50 000 USD/QALYs. Continuation of DAPT appears to be cost-effective in ACS patients who were event-free for 12-month DAPT after DES. The cost-effectiveness of DAPT for 30 months was highly subject to the OR of nonfatal stroke and OR of death with DAPT continuation.
药物洗脱支架（DES）植入后双联抗血小板治疗（DAPT）超过1年可降低晚期支架血栓形成和缺血事件，但会增加出血风险。我们假设，DES植入后急性冠状动脉综合征（ACS）患者将DAPT从12个月延长至30个月具有成本效益。设计了一个终身决策分析模型，以模拟DES植入后完成12个月DAPT的无事件ACS患者的两种抗血小板策略：阿司匹林单药治疗（每日75 - 162毫克）和继续DAPT（每日氯吡格雷75毫克加阿司匹林75 - 162毫克）18个月。从美国医疗保健提供者的角度来看，临床事件发生率、直接医疗成本和获得的质量调整生命年（QALY）是主要结果。基础病例结果显示，继续DAPT可获得更高的QALY（8.1769对8.1582 QALY），且成本更低（42,982美元对44,063美元）。单向敏感性分析发现，基础病例QALY对继续DAPT时心血管死亡的比值比（OR）敏感，基础病例成本对继续DAPT时非致命性卒中的OR敏感。当非致命性卒中和心血管死亡的OR分别低于1.241和1.188时，继续DAPT仍具有成本效益。在概率敏感性分析中，在支付意愿阈值为50,000美元/QALY的情况下，在10,000次蒙特卡洛模拟中，74.75%的模拟结果显示继续DAPT是首选策略。DES植入后接受12个月DAPT且无事件的ACS患者继续DAPT似乎具有成本效益。DAPT持续30个月的成本效益高度取决于非致命性卒中的OR和继续DAPT时的死亡OR。
