Eckman M H, Falk R H, Pauker S G
Department of Medicine, New England Medical Center, Boston, Mass 02111, USA.
Arch Intern Med. 1998;158(15):1669-77. doi: 10.1001/archinte.158.15.1669.
The most appropriate treatment(s) for patients with atrial fibrillation remains uncertain.
To examine the cost-effectiveness of anti-thrombotic and antiarrhythmic treatment strategies for atrial fibrillation.
We performed decision and cost-effectiveness analyses using a Markov state transition model. We gathered data from the English-language literature using MEDLINE searches and bibliographies from selected articles. We obtained financial data from nationwide physician-fee references, a medical center's cost accounting system, and one of New England's larger managed care organizations. We examined strategies that included combinations of cardioversion, antiarrhythmic therapy with quinidine, sotalol hydrochloride, or amiodarone, and anticoagulant or antiplatelet therapy.
For a 65-year-old man with nonvalvular atrial fibrillation, any intervention results in a significant gain in quality-adjusted life years (QALYs) compared with no specific therapy. Use of aspirin results in the largest incremental gain (1.2 QALYs). Cardioversion followed by the use of amiodarone and warfarin together is the most effective strategy, yielding a gain of 2.3 QALYs compared with no specific therapy. The marginal cost-effectiveness ratios of cardioversion followed by aspirin, with or without amiodarone, are $33800 per QALY and $10800 per QALY, respectively. Cardioversion followed by amiodarone and warfarin has a marginal cost-effectiveness ratio of $92400 per QALY compared with amiodarone and aspirin. Strategies that include cardioversion followed by either quinidine or sotalol are both more expensive and less effective than competing strategies.
Cardioversion of patients with nonvalvular atrial fibrillation followed by the use of aspirin alone or with amiodarone has a reasonable marginal cost-effectiveness ratio. While cardioversion followed by the use of amiodarone and warfarin results in the greatest gain in quality-adjusted life expectancy, it is expensive (ie, has a high marginal cost-effectiveness ratio) compared with aspirin and amiodarone. Finally, for patients who are bothered little by symptoms of atrial fibrillation, cardioversion followed by either aspirin or warfarin without subsequent antiarrhythmic therapy is the treatment of choice.
心房颤动患者最合适的治疗方法仍不明确。
研究心房颤动抗血栓和抗心律失常治疗策略的成本效益。
我们使用马尔可夫状态转移模型进行决策分析和成本效益分析。通过医学主题词表（MEDLINE）检索及所选文章的参考文献收集英文文献数据。我们从全国医师收费参考资料、一家医疗中心的成本核算系统以及新英格兰地区较大的一家管理式医疗组织获取财务数据。我们研究了包括复律、用奎尼丁、盐酸索他洛尔或胺碘酮进行抗心律失常治疗以及抗凝或抗血小板治疗组合的策略。
对于一名65岁的非瓣膜性心房颤动男性患者，与不进行特定治疗相比，任何干预措施都会使质量调整生命年（QALY）显著增加。使用阿司匹林带来的增量收益最大（1.2个QALY）。复律后联合使用胺碘酮和华法林是最有效的策略，与不进行特定治疗相比，可增加2.3个QALY。复律后使用阿司匹林，无论是否联合胺碘酮，其边际成本效益比分别为每QALY 33800美元和每QALY 10800美元。与胺碘酮和阿司匹林相比，复律后联合使用胺碘酮和华法林的边际成本效益比为每QALY 92400美元。包括复律后使用奎尼丁或索他洛尔的策略比其他竞争策略成本更高且效果更差。
非瓣膜性心房颤动患者复律后单独使用阿司匹林或联合胺碘酮具有合理的边际成本效益比。虽然复律后联合使用胺碘酮和华法林可使质量调整预期寿命增加最多，但与阿司匹林和胺碘酮相比成本较高（即边际成本效益比高）。最后，对于心房颤动症状困扰较小的患者，复律后使用阿司匹林或华法林且不进行后续抗心律失常治疗是首选治疗方法。
