Hostname: page-component-586b7cd67f-r5fsc Total loading time: 0 Render date: 2024-11-26T19:41:49.919Z Has data issue: false hasContentIssue false
  • English
  • Français

Microvolt T-wave alternans and the selective use of implantable cardioverter defibrillators for primary prevention: A cost-effectiveness study

Published online by Cambridge University Press:  31 March 2009

Kristian B. Filion ,
Xuanqian Xie ,
Charlotte J. van der Avoort ,
Nandini Dendukuri  and
James M. Brophy
Kristian B. Filion
Affiliation:
McGill University and McGill University Health Center
Xuanqian Xie
Affiliation:
McGill University Health Centre
Charlotte J. van der Avoort
Affiliation:
Radboud University Nijmegen Medical Center
Nandini Dendukuri
Affiliation:
McGill University and McGill University Health Centre
James M. Brophy
Affiliation:
McGill University and McGill University Health Centre
Get access Rights & Permissions [Opens in a new window]

Abstract

Objectives: Implantable cardioverter defibrillators (ICDs) are an effective but expensive treatment for the prevention of sudden cardiac deaths in patients with severe left-ventricular dysfunction. Recent studies suggest that microvolt T-wave alternans (MTWA) predicts mortality and severe arrhythmic events in this population. However, the impact of MTWA on ICD cost-effectiveness is unknown.

Methods: A Markov decision-analysis model evaluated three treatment strategies for primary prevention in patients with severe left-ventricular dysfunction: (i) medical therapy for all; (ii) ICD therapy for all; and (iii) selective ICD therapy based on non-negative (positive or indeterminate) MTWA test results. Incremental cost-effectiveness ratios (ICER) were calculated from the perspective of a third party payer using a 10-year time horizon. Sensitivity analyses examined the robustness of the estimates.

Results: A treatment strategy involving ICD therapy in all patients was associated with an ICER of $121,800/quality-adjusted life-year (QALY) compared with medical therapy, whereas a treatment strategy involving the selective use of ICDs based on MTWA test results was associated with an ICER of $108,900/QALY compared with medical therapy. Sensitivity analyses suggest that, under most scenarios, the selective use of ICDs based on MTWA results does not decrease the ICER to below $100,000/QALY.

Conclusion: MTWA only marginally improves the cost-effectiveness of ICDs for primary prevention in patients with severe left-ventricular dysfunction. There remains a need for improved means to effectively identify which patients will derive the greatest benefit from ICD implantation.

Keywords

ArrhythmiasCost-effectivenessImplantable cardioverter defibrillatorsMicrovolt T-wave AlternansPrimary prevention
Type
General Essays
Information
International Journal of Technology Assessment in Health Care , Volume 25 , Issue 2 , April 2009 , pp. 151 - 160
Copyright
Copyright © Cambridge University Press 2009

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

REFERENCES

1. Al-Khatib, SM, Anstrom, KJ, Eisenstein, EL et al. , Clinical and economic implications of the multicenter automatic defibrillator implantation trial-II. Ann Intern Med. 2005;142:593–600.CrossRefGoogle ScholarPubMed
2. Amit, G, Costantini, O, Super, DM, Rosenbaum, DS. Microvolt T-wave alternans and electrophysiological testing predict different arrhythmia outcomes: Lessons from the alternans before cardioverter defibrillator (ABCD) trial. J Am Coll Cardiol. 2008;51:A18.Google Scholar
3. Antiarrhythmics versus Implantable Defibrillators (AVID) Investigators. A comparison of antiarrhythmic-drug therapy with implantable defibrillators in patients resuscitated from near-fatal ventricular arrhythmias. The Antiarrhythmics versus Implantable Defibrillators (AVID) Investigators. N Engl J Med. 1997;337:1576–1583.CrossRefGoogle Scholar
4. Armoundas, AA, Hohnloser, SH, Ikeda, T, Cohen, RJ. Can microvolt T-wave alternans testing reduce unnecessary defibrillator implantation? Nat Clin Pract Cardiovasc Med. 2005;2:522–528.CrossRefGoogle ScholarPubMed
5. Bansch, D, Antz, M, Boczor, S et al. , Primary prevention of sudden cardiac death in idiopathic dilated cardiomyopathy: The cardiomyopathy trial (CAT). Circulation. 2002;105:1453–1458.CrossRefGoogle ScholarPubMed
6. Bardy, GH, Lee, KL, Mark, DB et al. , Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. N Engl J Med. 2005;352:225–237.CrossRefGoogle ScholarPubMed
7. Bigger, JT. Prophylactic use of implanted cardiac defibrillators in patients at high risk for ventricular arrhythmias after coronary-artery bypass graft surgery. N Engl J Med. 1997;337:1569–1575.CrossRefGoogle ScholarPubMed
8. Bloomfield, DM, Bigger, JT, Steinman, RC et al. , Microvolt T-wave alternans and the risk of death or sustained ventricular arrhythmias in patients with left ventricular dysfunction. J Am Coll Cardiol. 2006;47:456–463.CrossRefGoogle ScholarPubMed
9. Braga, SS, Vaninetti, R, Laporta, A, Picozzi, A, Pedretti, RFE. T wave alternans is a predictor of death in patients with congestive heart failure. Int J Cardiol. 2004;93:31–38.CrossRefGoogle Scholar
10. Briggs, AH. Handling uncertainty in cost-effectiveness models. Pharmacoeconomics. 2000;17:479–500.CrossRefGoogle ScholarPubMed
11. Bristow, MR, Saxon, LA, Boehmer, J et al. , Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure. N Engl J Med. 2004;350:2140–2150.CrossRefGoogle ScholarPubMed
12. Bryant, J, Brodin, H, Loveman, E, Clegg, A. Clinical effectiveness and cost-effectiveness of implantable cardioverter defibrillators for arrhythmias: A systematic review and economic evaluation. Int J Technol Assess Health Care. 2007;23:63–70.CrossRefGoogle ScholarPubMed
13. Buxton, M, Caine, N, Chase, D et al. , A review of the evidence on the effects and costs of implantable cardioverter defibrillator therapy in different patient groups, and modelling of cost-effectiveness and cost-utility for these groups in a UK context. Health Technol Assess. 2006;10:iii–xi, 1.CrossRefGoogle Scholar
14. Canadian Institute for Health Information (CIHI). Provincial and territorial government health expenditure by age group, sex and major category. http://www.cihi.ca/cihiweb/dispPage.jsp?cw_page=download_form_e&cw_sku=PTGHEAGSMC-PDF&cw_ctt=1&cw_dform=N (accessed September 19, 2007).Google Scholar
15. Chan, PS, Stein, K, Chow, T et al. , Cost-effectiveness of a microvolt T-wave alternans screening strategy for implantable cardioverter-defibrillator placement in the MADIT-II-eligible population. J Am Coll Cardiol. 2006;48:112–121.CrossRefGoogle ScholarPubMed
16. Chow, T, Kereiakes, DJ, Bartone, C et al. , Prognostic utility of microvolt T-wave alternans in risk stratification of patients with ischemic cardiomyopathy. J Am Coll Cardiol. 2006;47:1820–1827.CrossRefGoogle ScholarPubMed
17. Chu, HT, Cole, SR. Bivariate meta-analysis of sensitivity and specificity with sparse data: A generalized linear mixed model approach. J Clin Epidemiol. 2006;59:1331–1332.CrossRefGoogle Scholar
18. Cohen, RJ. Enhancing specificity without sacrificing sensitivity: Potential benefits of using microvolt T-wave alternans testing to risk stratify the MADIT-II population. Card Electrophysiol Rev. 2003;7:438–442.CrossRefGoogle ScholarPubMed
19. Connolly, SJ, Gent, M, Roberts, RS et al. , Canadian implantable defibrillator study (CIDS)—A randomized trial of the implantable cardioverter defibrillator against amiodarone. Circulation. 2000;101:1297–1302.CrossRefGoogle ScholarPubMed
20. Drummond, MF, Sculpher, MJ, Torrance, GW, O'Brien, BJ, Stoddart, GL. Cost analysis. Methods for the economic evaluation of health care programs. 3rd ed. Oxford: Oxford University Press; 2005:55–102.CrossRefGoogle Scholar
21. Eckman, MH, Falk, RH, Pauker, SG. Cost-effectiveness of therapies for patients with nonvalvular atrial fibrillation. Arch Intern Med. 1998;158:1669–1677.CrossRefGoogle ScholarPubMed
22. EuroQol Group. EQ-5D. http://www.euroqol.org/ (accessed April 20, 2008).Google Scholar
23. Ezekowitz, JA, Rowe, BH, Dryden, DM et al. , Systematic review: Implantable cardioverter defibrillators for adults with left ventricular systolic dysfunction. Ann Intern Med. 2007;147:251–262.CrossRefGoogle ScholarPubMed
24. Greenberg, D, Bakhai, A, Cohen, DJ. Can we afford to eliminate restenosis? Can we afford not to? J Am Coll Cardiol. 2004;43:513–518.CrossRefGoogle ScholarPubMed
25. Grimm, W, Christ, M, Bach, J, Muller, HH, Maisch, B. Noninvasive arrhythmia risk stratification in idiopathic dilated cardiomyopathy: Results of the Marburg cardiomyopathy study. Circulation. 2003;108:2883–2891.CrossRefGoogle ScholarPubMed
26. Hamza, TH, van Houwelingen, HC, Stijnen, T. The binomial distribution of meta-analysis was preferred to model within-study variability. J Clin Epidemiol. 2008;61:41–51.CrossRefGoogle ScholarPubMed
27. Hohnloser, SH, Kuck, KH, Dorian, P et al. , Prophylactic use of an implantable cardioverter-defibrillator after acute myocardial infarction. N Engl J Med. 2004;351:2481–2488.CrossRefGoogle ScholarPubMed
28. Hreybe, H, Bedi, M, Ezzeddine, R et al. , Indications for internal cardioverter defibrillator implantation predict time to first shock and the modulating effect of beta-blockers. Am Heart J. 2005;150:1064.CrossRefGoogle ScholarPubMed
29. Kadish, A, Dyer, A, Daubert, JP et al. , Prophylactic defibrillator implantation in patients with nonischemic dilated cardiomyopathy. N Engl J Med. 2004;350:2151–2158.CrossRefGoogle ScholarPubMed
30. Klingenheben, T, Ptaszynski, P. Clinical significance of microvolt T-wave alternans. Herzschrittmacherther Elektrophysiol. 2007;18:39–44.CrossRefGoogle ScholarPubMed
31. Klingenheben, T, Zabel, M, D'Agostino, RB, Cohen, RJ, Hohnloser, SH. Predictive value of T-wave alternans for arrhythmic events in patients with congestive heart failure. Lancet. 2000;356:651–652.CrossRefGoogle ScholarPubMed
32. Kuck, KH, Cappato, R, Siebels, J, Ruppel, R. Randomized comparison of antiarrhythmic drug therapy with implantable defibrillators in patients resuscitated from cardiac arrest: The Cardiac Arrest Study Hamburg (CASH). Circulation. 2000;102:748–754.CrossRefGoogle ScholarPubMed
33. Laupacis, A, Feeny, D, Detsky, AS, Tugwell, PX. How attractive does a new technology have to be to warrant adoption and utilization: Tentative guidelines for using clinical and economic evaluations. CMAJ. 1992;146:473–481.Google ScholarPubMed
34. Le Heuzey, JY, Paziaud, O, Piot, O et al. , Cost of care distribution in atrial fibrillation patients: The COCAF study. Am Heart J. 2004;147:121–126.CrossRefGoogle Scholar
35. Maisel, WH, Sweeney, MO, Stevenson, WG, Ellison, KE, Epstein, LM. Recalls and safety alerts involving pacemakers and implantable cardioverter-defibrillator generators. JAMA. 2001;286:793–799.CrossRefGoogle ScholarPubMed
36. Marshall, DA, Levy, AR, Vidaillet, H et al. , Cost-effectiveness of rhythm versus rate control in atrial fibrillation. Ann Intern Med. 2004;141:653–661.CrossRefGoogle ScholarPubMed
37. McGregor, M, Chen, J. Use of the implantable cardiac defibrillator (ICD) at the McGill University Health Centre (MUHC). A technology assessment. By the McGill University Health Centre, Montreal, Quebec; 2004. http://www.mcgill.ca/files/tau/icd.pdf (accessed September 15, 2007).Google Scholar
38. Miners, A, Cairns, J. Probabilistic sensitivity analysis. In: Fox-Rushby, J, Cairns, J, eds. Economic evaluation (understanding public health). OZGraf.S.A: Open University Press; 2005:171–183.Google Scholar
39. Moss, AJ, Hall, WJ, Cannom, DS et al. , Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia. N Engl J Med. 1996;335 (26):1933–1940.CrossRefGoogle ScholarPubMed
40. Moss, AJ, Zareba, W, Hall, WJ et al. , Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. N Engl J Med. 2002;346:877–883.CrossRefGoogle ScholarPubMed
41. Mushlin, AI, Hall, WJ, Zwanziger, J et al. , The cost-effectiveness of automatic implantable cardiac defibrillators: Results from MADIT. Circulation. 1998;97:2129–2135.CrossRefGoogle ScholarPubMed
42. O'Brien, BJ, Connolly, SJ, Goeree, R et al. , Cost-effectiveness of the implantable cardioverter-defibrillator – Results from the Canadian Implantable Defibrillator Study (CIDS). Circulation. 2001;103:1416–1421.CrossRefGoogle ScholarPubMed
43. Organisation for Economic Co-operation and Development. Purchasing power parities (PPPs). http://www.oecd.org/department/0,3355,en_2649_34357_1_1_1_1_1,00.html (accessed September 18, 2007).Google Scholar
44. Owens, DK, Sanders, GD, Harris, RA et al. , Cost-effectiveness of implantable cardioverter defibrillators relative to amiodarone for prevention of sudden cardiac death. Ann Intern Med. 1997;126:1–12.CrossRefGoogle ScholarPubMed
45. Public Health Agency of Canada. Major chronic diseases mortality by age group. http://dsol-smed.phac-aspc.gc.ca/dsol-smed/mcd-smcm/d_age_e.html (accessed September 20, 2007).Google Scholar
46. Sakabe, K, Ikeda, T, Sakata, T et al. , Comparison of T-wave alternans and QT interval dispersion to predict ventricular tachy-arrhythmia in patients with dilated cardiomyopathy and without antiarrhythmic drugs: A prospective study. Jpn Heart J. 2001;42:451–457.CrossRefGoogle Scholar
47. Sanders, GD, Hlatky, MA, Owens, DK. Cost-effectiveness of implantable cardioverter-defibrillators. N Engl J Med. 2005;353:1471–1480.CrossRefGoogle ScholarPubMed
48. Medical, St. Jude. ICD implantation. http://www.sjm.com/procedures/procedure.aspx?name=ICD+Implantation&section=FAQ#109 (accessed September 20, 2007).Google Scholar
49. Statistics Canada. Consumer price index (CPI). http://www.statcan.ca/english/Subjects/Cpi/cpi-en.htm (accessed September 20, 2007).Google Scholar
50. Stiell, IG, Wells, GA, Demaio, VJ et al. , Modifiable factors associated with improved cardiac arrest survival in a multicenter basic life support/defibrillation system: OPALS study phase I results. Ann Emerg Med. 1999;33:44–50.CrossRefGoogle Scholar
51. Strickberger, SA, Hummel, JD, Bartlett, TG et al. , Amiodarone versus implantable cardioverter-defibrillator: Randomized trial in patients with nonischemic dilated cardiomyopathy and asymptomatic nonsustained ventricular tachycardia – AMIOVIRT. J Am Coll Cardiol. 2003;41:1707–1712.CrossRefGoogle ScholarPubMed
52. Teng, J, Mayo, NE, Latimer, E et al. , Costs and caregiver consequences of early supported discharge for stroke patients. Stroke. 2003;34:528–536.CrossRefGoogle ScholarPubMed
53. Van Der Avoort, CJ, Filion, KB, Dendukuri, N, Brophy, JM. Microvolt T-wave alternans as a predictor of mortality and severe arrhythmias in patients with left-ventricular dysfunction: A systematic review and meta-analysis. BMC Cardiovasc Disord. 2009 Jan 28; 9:5. [Epub ahead of print]CrossRefGoogle ScholarPubMed
54. Verrier, RL, Kumar, K, Josephson, ME. The frustrating search for arrhythmia risk stratifiers in heart failure due to nonischemic cardiomyopathy: Does T-wave alternans testing help? J Am Coll Cardiol. 2007;50:1905–1906.CrossRefGoogle ScholarPubMed
55. Wilkoff, BL, Hess, M, Young, J, Abraham, WT. Differences in tachyarrhythmia detection and implantable cardioverter defibrillator therapy by primary or secondary prevention indication in cardiac resynchronization therapy patients. J Cardiovasc Electrophysiol. 2004;15:1002–1009.CrossRefGoogle ScholarPubMed
56. Yao, GQ, Freemantle, N, Calvert, MJ et al. , The long-term cost-effectiveness of cardiac resynchronization therapy with or without an implantable cardioverter-defibrillator. Eur Heart J. 2007;28:42–51.CrossRefGoogle ScholarPubMed