[Evaluation of the cost-effectiveness of thrombolytic therapy in acute myocardial infarct using tissue plasminogen activator or streptokinase:the Italian perspective].

UNLABELLED

The GUSTO trial demonstrated that tPA is more effective than streptokinase in the therapy for acute myocardial infarction (AMI). Although tPA is much more expensive than streptokinase some recent analyses have demonstrated that the use of this drug is also cost-effective. However, the cost of the two drugs is different in Italy and USA. Moreover, the difference of the efficacy of the two drugs varies greatly among subgroups of patients with AMI. The aim of this study was to assess the cost-effectiveness of the exclusive use of tPA and streptokinase in the general population and in subgroups of patients divided according to age and site of AMI, using the costs of the drugs in Italy (streptokinase 100,600 and tPA 1,524,300 Italian Liras (ItL)/treatment).

METHODS

The results of the GUSTO trial (30 day-mortality) obtained in the general population and subgroups (< or = 75 years and > 75 years; anterior AMI and non-anterior AMI) were applied to patients enrolled in the GISSI-2 trial. The number of lives saved and the incremental costs for each life saved were calculated for the use of tPA in respect to the use of streptokinase. Results are referred to the treatment of 1000 patients.

RESULTS

In the general population, in respect to the use of streptokinase, the use of tPA would save 10 lives at an incremental cost of 142.370 millions ItL/life saved. The use of tPA in patients aged < or = 75 years would save 11 patients at the incremental cost of 129.427 millions ItL/life saved, while the use of tPA in patients aged > 75 years would save 13 patients at the incremental cost of 109.515 millions ItL/life saved. In anterior AMI, tPA can save 19 patients at the additional cost of 74.932 millions ItL/life saved, while in non-anterior AMI it can save 6 patients at the additional cost of 237.238 millions ItL/life saved. A subgroup analysis demonstrated that 9 lives can be saved with the use of tPA in anterior AMI and streptokinase in non-anterior AMI at the cost of 49.038 millions ItL/life saved, in respect to the exclusive use of streptokinase.

CONCLUSIONS

1. The cost-effectiveness ratio of tPA in the general population with AMI is comparable to that of other expensive therapies (< 150 millions ItL/life saved). 2. However, a strategy implying a selective use of the two drugs is far more cost-effective (< 50 millions ItL/life saved).