From the Icahn School of Medicine at Mount Sinai Medical Center, New York, NY (V.Y.R.)
BresMed, Sheffield, United Kingdom (R.L.A.).
Stroke. 2018 Jun;49(6):1464-1470. doi: 10.1161/STROKEAHA.117.018825. Epub 2018 May 8.
Once a patient with atrial fibrillation experiences an embolic event, the risk of a recurrent event increases 2.6-fold. New treatments have emerged as viable treatment alternatives to warfarin for stroke risk reduction in secondary prevention populations. This analysis sought to assess the cost-effectiveness of left atrial appendage closure (LAAC) compared with warfarin and the non-vitamin K antagonist oral anticoagulants dabigatran 150 mg, apixaban and rivaroxaban in the prevention of stroke in nonvalvular atrial fibrillation patients with a prior stroke or transient ischemic attack.
A Markov model was constructed using data from the secondary prevention subgroup analyses of the non-vitamin K antagonist oral anticoagulant and LAAC pivotal trials. Costs were from 2016 US Medicare reimbursement rates and the literature. The cost-effectiveness analysis was conducted from a US Medicare perspective over a lifetime (20 years) horizon. The model was populated with a cohort of 10 000 patients aged 70 years with a CHADS-VASc score of 7 (annual stroke risk=9.60%) and HAS-BLED score of 3 (annual bleeding risk=3.74%).
LAAC achieved cost-effectiveness relative to dabigatran at year 5 and warfarin and apixaban at year 6. At 10 years, LAAC had more quality-adjusted life years (4.986 versus 4.769, 4.869, 4.888, and 4.810) and lower costs ($42 616 versus $53 770, $58 774, $55 656, and $58 655) than warfarin, dabigatran, apixaban, and rivaroxaban, respectively, making LAAC the dominant (more effective and less costly) stroke risk reduction strategy. LAAC remained the dominant strategy over the lifetime analysis.
Upfront procedure costs initially make LAAC higher cost than warfarin and the non-vitamin K antagonist oral anticoagulants, but within 10 years, LAAC delivers more quality-adjusted life years and has lower total costs, making LAAC the most cost-effective treatment strategy for secondary prevention of stroke in atrial fibrillation.
一旦房颤患者发生栓塞事件，其复发风险增加 2.6 倍。对于二级预防人群，新型治疗方法已经作为华法林治疗卒中风险的替代方法出现。本分析旨在评估左心耳封堵术（LAAC）与华法林及非维生素 K 拮抗剂口服抗凝剂达比加群 150mg、阿哌沙班和利伐沙班在预防非瓣膜性房颤伴既往卒中和短暂性脑缺血发作患者卒中的成本效益。
使用非维生素 K 拮抗剂口服抗凝剂和 LAAC 关键试验的二级预防亚组分析数据构建了一个 Markov 模型。成本来自 2016 年美国医疗保险报销率和文献。该成本效益分析从美国医疗保险的角度在 20 年的时间范围内进行。该模型纳入了 10000 名年龄为 70 岁、CHADS-VASc 评分为 7（年卒中风险为 9.60%）和 HAS-BLED 评分为 3（年出血风险为 3.74%）的患者队列。
LAAC 在第 5 年相对于达比加群、第 6 年相对于华法林和阿哌沙班具有成本效益。在第 10 年，LAAC 具有更高的质量调整生命年（4.986 比 4.769、4.869、4.888 和 4.810）和更低的成本（42616 美元比 53770 美元、58774 美元、55656 美元和 58655 美元），优于华法林、达比加群、阿哌沙班和利伐沙班，使 LAAC 成为降低卒中风险的主导策略（更有效且成本更低）。LAAC 在整个生命周期分析中仍然是主导策略。
最初，LAAC 的手术费用比华法林和非维生素 K 拮抗剂口服抗凝剂高，但在 10 年内，LAAC 提供了更多的质量调整生命年，并降低了总成本，使其成为房颤二级预防卒中的最具成本效益的治疗策略。
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