Dhruv S. Kazi, MD, MSc, MS; Alan M. Garber, MD, PhD; Rashmee U. Shah, MD, MS; R. Adams Dudley, MD, MBA; Matthew W. Mell, MD; Ceron Rhee, MBA; Solomon Moshkevich, MBA; Derek B. Boothroyd, PhD; Douglas K. Owens, MD; Mark A. Hlatky, MD
Disclaimer: The findings and conclusions in this article are those of the authors and do not necessarily represent the views of the U.S. Department of Veterans Affairs.
Acknowledgments: The authors thank Phil Lavori, PhD, Department of Health Research and Policy, and Jay Bhattacharya, MD, PhD, and Matthew Franzen, Centers for Health Policy and Primary Care and Outcomes Research, Stanford University, for their help and guidance with the analysis. They also thank Kristin Sainani, PhD, Department of Health Research and Policy, for her comments on a previous version of the manuscript and Elaine Steel, Beth Thew, L. Marie Dach, and Antonella Vassallo for their administrative support.
Grant Support: Funded in part by the American Heart Association Pharmaceutical Roundtable–Spina Outcomes Research Center (0875162N), U.S. Department of Veterans Affairs, Stanford University, and the University of California San Francisco.
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-1999.
Reproducible Research Statement: Statistical protocol: Available from Dr Kazi (firstname.lastname@example.org). Statistical code and data set: Not available.
Requests for Single Reprints: Dhruv S. Kazi, MD, MSc, MS, Division of Cardiology, San Francisco General Hospital, 1001 Potrero Avenue, Room 5G1, San Francisco, CA 94110; e-mail, email@example.com.
Current Author Addresses: Dr. Kazi: Division of Cardiology, San Francisco General Hospital, 1001 Potrero Avenue, Room 5G1, San Francisco, CA 94110.
Dr. Garber: Office of the President and Provost, Harvard University, Massachusetts Hall, Harvard Yard, Cambridge, MA 02138.
Dr. Shah: University of Pittsburgh Medical Center, 200 Lothrop Street, B-571.3 Scaife Hall, Pittsburgh, PA 15213.
Dr. Dudley: Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, 3333 California Street, Suite 265, San Francisco, CA 94118.
Dr. Mell: Stanford Medical Center Vascular Surgery Clinic, 300 Pasteur Drive H3600, MC5642 Stanford, CA 94305.
Mr. Rhee: 13078 Via Escuela Court, Saratoga, CA 95070.
Mr. Moshkevich: 544 Guerrero Street, #3, San Francisco, CA 94110.
Dr. Boothroyd: Stanford University School of Medicine, Department of Health Research and Policy, HRP Redwood Building, Room T150, 259 Campus Drive, Stanford, CA 94305-5405.
Dr. Owens: Stanford University, Center for Health Policy and Center for Primary Care and Outcomes Research, 117 Encina Commons, Room 201, Stanford, CA 94305-6019.
Dr. Hlatky: Stanford University School of Medicine, Department of Health Research and Policy, HRP Redwood Building, Room T150, 259 Campus Drive, Stanford, CA 94305-5405.
Author Contributions: Conception and design: D.S. Kazi, M.W. Mell, C. Rhee, D.K. Owens, M.A. Hlatky.
Analysis and interpretation of the data: D.S. Kazi, A.M. Garber, M.W. Mell, S. Moshkevich, D.K. Owens, M.A. Hlatky.
Drafting of the article: D.S. Kazi.
Critical revision of the article for important intellectual content: D.S. Kazi, A.M. Garber, R.U. Shah, R.A. Dudley, M.W. Mell, S. Moshkevich, D.B. Boothroyd, D.K. Owens, M.A. Hlatky.
Final approval of the article: D.S. Kazi, A.M. Garber, R.U. Shah, R.A. Dudley, M.W. Mell, D.K. Owens.
Provision of study materials or patients: D.S. Kazi.
Statistical expertise: D.S. Kazi, A.M. Garber, R.U. Shah, D.B. Boothroyd, D.K. Owens, M.A. Hlatky.
Obtaining of funding: M.A. Hlatky.
Administrative, technical, or logistic support: D.S. Kazi, A.M. Garber, R.A. Dudley, M.A. Hlatky.
Collection and assembly of data: D.S. Kazi, R.U. Shah, M.W. Mell, C. Rhee, S. Moshkevich, D.B. Boothroyd
Kazi DS, Garber AM, Shah RU, Dudley RA, Mell MW, Rhee C, et al. Cost-Effectiveness of Genotype-Guided and Dual Antiplatelet Therapies in Acute Coronary Syndrome. Ann Intern Med. 2014;160:221-232. doi: 10.7326/M13-1999
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Published: Ann Intern Med. 2014;160(4):221-232.
The choice of antiplatelet therapy after acute coronary syndrome (ACS) is complicated: Ticagrelor and prasugrel are novel alternatives to clopidogrel, patients with some genotypes may not respond to clopidogrel, and low-cost generic formulations of clopidogrel are available.
To determine the most cost-effective strategy for dual antiplatelet therapy after percutaneous coronary intervention for ACS.
Published literature, Medicare claims, and life tables.
Patients having percutaneous coronary intervention for ACS.
Five strategies were examined: generic clopidogrel, prasugrel, ticagrelor, and genotyping for polymorphisms of CYP2C19 with carriers of loss-of-function alleles receiving either ticagrelor (genotyping with ticagrelor) or prasugrel (genotyping with prasugrel) and noncarriers receiving clopidogrel.
Direct medical costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs).
The clopidogrel strategy produced $179 301 in costs and 9.428 QALYs. Genotyping with prasugrel was superior to prasugrel alone, with an ICER of $35 800 per QALY relative to clopidogrel. Genotyping with ticagrelor was more effective than genotyping with prasugrel ($30 200 per QALY relative to clopidogrel). Ticagrelor was the most effective strategy ($52 600 per QALY relative to genotyping with ticagrelor).
Stronger associations between genotype and thrombotic outcomes rendered ticagrelor substantially less cost-effective ($104 800 per QALY). Genotyping with prasugrel was the preferred therapy among patients who could not tolerate ticagrelor.
No randomized trials have directly compared genotyping strategies or prasugrel with ticagrelor.
Genotype-guided personalization may improve the cost-effectiveness of prasugrel and ticagrelor after percutaneous coronary intervention for ACS, but ticagrelor for all patients may be an economically reasonable alternative in some settings.
American Heart Association, U.S. Department of Veterans Affairs, Stanford University, and University of California San Francisco.
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Acute Coronary Syndromes, Cardiology, Coronary Heart Disease, Emergency Medicine, Healthcare Delivery and Policy.
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