Duke Center for Applied Genomics & Precision Medicine, Department of Medicine, Duke University School of Medicine, 101 Science Dr. CIEMAS Building, Durham, NC 27708, USA.
Durham VA Health Care System, 508 Fulton St, Durham, NC 27705, USA.
Eur Heart J Qual Care Clin Outcomes. 2023 Apr 26;9(3):249-257. doi: 10.1093/ehjqcco/qcac031.
CYP2C19-guided P2Y12 inhibitor selection can reduce cardiovascular (CV) events and bleeding in patients with acute coronary syndromes (ACSs) post-percutaneous coronary intervention (PCI). The 12-month cost-effectiveness of CYP2C19-guided P2Y12 inhibitor selection for Veterans post-ACS/PCI was evaluated from the Veterans Health Administration's (VHA) perspective.
Using average annualized PCI volumes and P2Y12 inhibitor use from VA data, a decision-analytic model simulated CYP2C19 testing vs. no testing outcomes in 2800 hypothetical Veterans receiving PY212 inhibitor for 12 months post-ACS/PCI (74% clopidogrel, 5% prasugrel, and 21% ticagrelor use at baseline without testing). CYP2C19 loss-of-function (LOF) carrier prevalence was 28%. Model inputs were from studies (bleeding/ischaemic events, CYP2C19-guided therapy effect, health state utilities, CYP2C19 LOF carrier prevalence) and VHA administrative data (costs of events, drugs, CYP2C19 testing; PCI volumes, and P2Y12 inhibitor prescriptions). The primary outcome was cost (2020 US${$}$) per quality-adjusted life year (QALY) gained. Base-case scenarios, probabilistic sensitivity analyses, and scenario analyses were completed. CYP2C19-guided therapy resulted in 496 (24%) escalations (clopidogrel to prasugrel/ticagrelor) and 465 (65%) de-escalations (prasugrel/ticagrelor to clopidogrel). CYP2C19 testing averted 1 stroke, 27 myocardial infarctions, 8 CV-related deaths, and caused 3 bleeds. CYP2C19 testing (vs. no testing) was dominant in the base-case scenario (0.0027 QALYs gained, ${$}$527 saved/person) and in 97.1% of simulations, making it cost-effective and high-value. In scenario analyses, de-escalation in conjunction with escalation is required for CYP2C19 testing to be cost-effective and high-value.
In Veterans post-ACS/PCI, CYP2C19-guided P2Y12 inhibitor selection can improve CV outcomes and lower costs for the VHA within 12 months of implementation.
CYP2C19 指导的 P2Y12 抑制剂选择可降低经皮冠状动脉介入治疗（PCI）后急性冠脉综合征（ACS）患者的心血管（CV）事件和出血风险。本研究从美国退伍军人事务部（VA）的角度评估了 CYP2C19 指导的 P2Y12 抑制剂选择在 ACS/PCI 后退伍军人中的 12 个月成本效益。
使用 VA 数据中平均年度 PCI 量和 P2Y12 抑制剂使用量，在 2800 名接受 12 个月 ACS/PCI 后接受 P2Y12 抑制剂治疗的假设退伍军人中，模拟 CYP2C19 检测与不检测的结果（氯吡格雷 74%，普拉格雷 5%，替卡格雷 21%，基线时无检测）。CYP2C19 失活（LOF）携带者的患病率为 28%。模型输入来自研究（出血/缺血事件、CYP2C19 指导治疗效果、健康状态效用、CYP2C19 LOF 携带者患病率）和 VA 管理数据（事件、药物、CYP2C19 检测成本；PCI 量和 P2Y12 抑制剂处方）。主要结果是每获得 1 个质量调整生命年（QALY）的成本（2020 年美国美元）。完成了基础案例场景、概率敏感性分析和方案分析。CYP2C19 指导治疗导致 496 例（24%）升级（氯吡格雷转换为普拉格雷/替格瑞洛）和 465 例（65%）降级（普拉格雷/替格瑞洛转换为氯吡格雷）。CYP2C19 检测避免了 1 例中风、27 例心肌梗死、8 例心血管相关死亡和 3 例出血。在基础案例中（获得 0.0027 个 QALY，每人节省 527 美元）和 97.1%的模拟中，CYP2C19 检测（与不检测相比）是优势策略，使其具有成本效益和高价值。在方案分析中，CYP2C19 检测要具有成本效益和高价值，需要结合降级和升级。
在 ACS/PCI 后退伍军人中，CYP2C19 指导的 P2Y12 抑制剂选择可改善 CV 结局并降低 VA 在 12 个月内的成本。
