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Cost-Effectiveness of Cardioversion and Antiarrhythmic Therapy in Nonvalvular Atrial Fibrillation

Edward Catherwood, MD, MS; W. David Fitzpatrick, MD; Mark L. Greenberg, MD; Peter T. Holzberger, MD; David J. Malenka, MD; Barbara R. Gerling, MD; and John D. Birkmeyer, MD
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From Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Dartmouth Medical School, Hanover, New Hampshire; and Veterans Affairs Outcomes Group, Department of Veterans Affairs Medical Center, White River Junction, Vermont.

Ann Intern Med. 1999;130(8):625-636. doi:10.7326/0003-4819-130-8-199904200-00002
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Background: Physicians managing patients with nonvalvular atrial fibrillation must consider the risks, benefits, and costs of treatments designed to restore and maintain sinus rhythm compared with those of rate control with antithrombotic prophylaxis.

Objective: To compare the cost-effectiveness of cardioversion, with or without antiarrhythmic agents, with that of rate control plus warfarin or aspirin.

Design: A Markov decision-analytic model was designed to simulate long-term health and economic outcomes.

Data Sources: Published literature and hospital accounting information.

Target Population: Hypothetical cohort of 70-year-old patients with different baseline risks for stroke.

Time Horizon: 3 months.

Perspective: Societal.

Intervention: Therapeutic strategies using different combinations of cardioversion alone, cardioversion plus amiodarone or quinidine therapy, and rate control with antithrombotic treatment.

Outcome Measures: Expected costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness.

Results of Base-Case Analysis: Strategies involving cardioversion alone were more effective and less costly than those not involving this option. For patients at high risk for ischemic stroke (5.3% per year), cardioversion alone followed by repeated cardioversion plus amiodarone therapy on relapse was most cost-effective ($9300 per QALY) compared with cardioversion alone followed by warfarin therapy on relapse. This strategy was also preferred for the moderate-risk cohort (3.6% per year), but the benefit was more expensive ($18 900 per QALY). In the lowest-risk cohort (1.6% per year), cardioversion alone followed by aspirin therapy on relapse was optimal.

Results of Sensitivity Analysis: The choice of optimal strategy and incremental cost-effectiveness was substantially influenced by the baseline risk for stroke, rate of stroke in sinus rhythm, efficacy of warfarin, and costs and utilities for long-term warfarin and amiodarone therapy.

Conclusions: Cardioversion alone should be the initial management strategy for persistent nonvalvular atrial fibrillation. On relapse of arrhythmia, repeated cardioversion plus low-dose amiodarone is cost-effective for patients at moderate to high risk for ischemic stroke.


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Figure 1.
Simplified diagram of the Markov decision-analytic model.M

The square at left represents the decision to follow one of the treatment strategies. The indicates the Markov process, which leads to one of several health states. Circles represent chance events that may occur during each cycle and result in continued good health, one of several temporary or permanent disabling events, or death. Health states in the figure are simplified, and each represents multiple states in the actual model (for example, “disabled in NSR” includes patients in sinus rhythm with disability due to stroke, intracerebral hemorrhage, or chronic pulmonary toxicity caused by amiodarone). AF = atrial fibrillation; CNS = central nervous system (intracranial); CV = cardioversion; Mod-Sev = moderate to severe; nonCNS = extracranial; NSR = normal sinus rhythm.

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Figure 2.
Cost and effectiveness of eight treatment strategies in patients at moderate risk for ischemic stroke.CV

Strategies involving cardioversion ( ) alone as the initial approach are more effective and less expensive than other strategies. QALY = quality-adjusted life-year.

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Figure 3.
Sensitivity analysis of the rate of ischemic stroke with no therapy and the effectiveness of strategies involving cardioversion alone.arrowscrossesQALYssquares

Risk groups are shown with their respective ranges ( ). At the lowest rates of stroke, cardioversion followed by aspirin therapy on relapse ( ) provided the most benefit in quality-adjusted life-years ( ). Cardioversion alone followed by repeated cardioversion plus amiodarone therapy on relapse ( ) offered the most benefit for patients at moderate to high risk for ischemic stroke with no therapy. Although the range of ischemic stroke extends to 18% per year in the high-risk category, the upper bound in the figure is 8% per year for illustration purposes. Diamonds represent cardioversion alone followed by repeated cardioversion plus quinidine therapy on relapse; triangles represent cardioversion followed by warfarin therapy on relapse.

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Figure 4.
Tornado diagram of variables with significant influence on cost-effectiveness.Table 1white bars; striped bars;

The diagram showed variables identified in the sensitivity analysis that substantially affect the incremental cost-effectiveness when evaluated across the range of estimates from . The analysis includes cardioversion alone followed by repeated cardioversion plus amiodarone therapy on relapse compared with cardioversion followed by warfarin therapy on relapse. The analysis was performed at base-case estimates for moderate risk ( 3.6% per year) and high risk ( 5.3% per year) for ischemic stroke with no therapy. “Dominated” means that the incremental cost-effectiveness ratio reaches the threshold value beyond which the comparison strategy is less costly and more effective. See text for details. QALY = quality-adjusted life-year.

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