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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
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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

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