The cost–effectiveness of strategies in coronary artery disease

Abstract

Coronary artery disease has significant social and economic implications. Health expenditures have increased in recent decades, more than the economy itself, with significant consequences, either reducing spending in other areas or increasing the budget deficit. It is necessary to create tools to identify the most cost-effective treatments, which can assist clinicians in their therapeutic decisions so that the maximum possible benefit is reached with the lowest possible cost. Efficiency must be measured by final treatment goals in which the most effective interventions are those with the lowest costs. We analyzed the cost–effectiveness of coronary artery disease treatment strategies, medical treatment, percutaneous coronary intervention and coronary artery bypass surgery, with a focus on comparative analyses between these treatment modalities.

Keywords::

• coronary artery bypass graft
• coronary artery disease
• cost–effectiveness
• myocardial ischemia
• percutaneous coronary intervention

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Cost–effectiveness is an economic evaluation that reflects the health gain due to a specific intervention and the monetary cost to obtain the health gain.

• Long-term cost–effectiveness analysis has shown that medical treatment is cost-effective compared with PCI and CABG.

• The cost–effectiveness analysis has demonstrated that CABG is superior to PCI with balloon or bare metal stent for patients with multivessel coronary disease, particularly in diabetic patients.

• As demonstrated by cost–effectiveness analysis of the FREEDOM trial, CABG is more cost-effective than drug eluting stent (DES) in patients with multivessel coronary disease and diabetes. However, in patients with coronary artery disease without diabetes, DES can be an interesting strategy due to its lower rates of restenosis.

• Studies have demonstrated that DES is not cost-effective in widespread populations. But it may be cost-effective in select subgroups of patients, such as patients at high risk for restenosis.

• Fractional flow reserve-guided PCI may be cost-effective compared with standard PCI based on visual assessment of angiography, adding support to the importance of a functional evaluation to guide PCI treatment.

• There is controversy about the cost–effectiveness of on-pump versus off-pump surgery, since no study analyzed the results of long-term follow-up.