Using triple antiplatelet therapy in patients with non-ST elevation acute coronary syndrome managed invasively: a cost-effectiveness analysis.

Objectives: To assess the incremental cost-effectiveness ratio (ICER) of glycoprotein IIb/IIIa (GPIIb/IIIa) inhibitors in patients with non-ST elevation acute coronary syndrome (NSTE-ACS) pretreated with aspirin and clopidogrel undergoing an early invasive treatment strategy.

Methods: Cost-effectiveness analysis and cost-utility analysis were performed from a health-care system perspective, based on a Markov model with a time horizon of the patient life span. The risk of death and ischemic events was assessed using the Thrombolysis in Myocardial Infarction (TIMI) risk score. We compared three strategies: 1) routine upstream use of a GPIIb/IIIa inhibitor to all patients before angiography, 2) deferred selective use of abciximab in the catheterization laboratory just before angioplasty, and 3) double antiplatelet therapy without GPIIb/IIIa inhibitors. Both univariate sensitivity analysis and second-order probabilistic microsimulation were performed.

Results: In the base case (65 years old, TIMI score 3), strategy A was the most effective, with an ICER of 15,150 euros per quality-adjusted life-year gained. Strategy B was dominated by a combination of strategies A and C. The ICER was very sensitive to the age and baseline risk of the patient. According to the widely accepted cost-effectiveness thresholds, strategy A would be cost-effective only in patients with an intermediate to high TIMI score, especially within the younger age groups. The probability that strategy A was cost-effective under the base case was 91.2%.

Conclusions: The use of GPIIb/IIIa inhibitors upstream in high-risk NSTE-ACS patients (TIMI score > or = 3) pretreated with aspirin and clopidogrel is cost-effective, particularly in the younger age groups.