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Article Text

Health economics
Potential economic consequences of a cardioprotective agent for patients with myocardial infarction: modelling study

Objective To investigate the cost-effectiveness of a hypothetical cardioprotective agent used to reduce infarct size in patients undergoing percutaneous coronary intervention (PCI) after anterior ST-elevation myocardial infarction.

Methods : A cost-utility analysis using a Markov model. : The National Health Service in the UK. : Patients undergoing PCI after anterior ST-elevation myocardial infarction. : A cardioprotective agent given at the time of reperfusion compared to no cardioprotection. We assumed the cardioprotective agent (given at the time of reperfusion) would reduce the risk and severity of heart failure (HF) after PCI and the risk of mortality after PCI (with a relative risk ranging from 0.6 to 1). The costs of the cardioprotective agent were assumed to be in the range £1000–4000. : The incremental costs per quality-adjusted life-year (QALY) gained, using 95% CIs from 1000 simulations.

Results Incremental costs ranged from £933 to £3820 and incremental QALYs from 0.04 to 0.38. The incremental cost-effectiveness ratio (ICER) ranged from £3311 to £63 480 per QALY gained. The results were highly dependent on the costs of a cardioprotective agent, patient age, and the relative risk of HF after PCI. The ICER was below the willingness-to-pay threshold of £20 000 per QALY gained in 71% of the simulations.

Conclusions A cardioprotective agent that can reduce the risk of HF and mortality after PCI has a high chance of being cost-effective. This chance depends on the price of the agent, the age of the patient and the relative risk of HF after PCI.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

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Strengths and limitations of this study

A strength of this study is that a model is presented that can be used for any potential cardioprotective agent to study the economic consequences of implementing this agent in clinical practice. If the effect of the new drug on the incidence of heart failure after PCI is known, this model can be updated to present a more precise estimate of the cost-effectiveness of this drug.

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Clinical Investigation and Reports
Romualdo Belardinelli , Demetrios Georgiou , Giovanni Cianci , Augusto Purcaro
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Circulation. 1999; 99: 1173-1182
Romualdo Belardinelli
Demetrios Georgiou
Giovanni Cianci
Augusto Purcaro


—It is still a matter of debate whether exercise training (ET) is a beneficial treatment in chronic heart failure (CHF).

—To determine whether long-term moderate ET improves functional capacity and quality of life in patients with CHF and whether these effects translate into a favorable outcome, 110 patients with stable CHF were initially recruited, and 99 (59±14 years of age; 88 men and 11 women) were randomized into 2 groups. One group (group T, n=50) underwent ET at 60% of peak V̇ o , initially 3 times a week for 8 weeks, then twice a week for 1 year. Another group (group NT, n=49) did not exercise. At baseline and at months 2 and 14, all patients underwent a cardiopulmonary exercise test, while 74 patients (37 in group T and 37 in group NT) with ischemic heart disease underwent myocardial scintigraphy. Quality of life was assessed by questionnaire. Ninety-four patients completed the protocol (48 in group T and 46 in group NT). Changes were observed only in patients in group T. Both peak V̇ o and thallium activity score improved at 2 months (18% and 24%, respectively; <0.001 for both) and did not change further after 1 year. Quality of life also improved and paralleled peak V̇ o . Exercise training was associated both with lower mortality (n=9 versus n=20 for those with training versus those without; relative risk (RR)=0.37; 95% CI, 0.17 to 0.84; =0.01) and hospital readmission for heart failure (5 versus 14; RR=0.29; 95% CI, 0.11 to 0.88; =0.02). Independent predictors of events were ventilatory threshold at baseline (β-coefficient=0.378) and posttraining thallium activity score (β-coefficient −0.165).

—Long-term moderate ET determines a sustained improvement in functional capacity and quality of life in patients with CHF. This benefit seems to translate into a favorable outcome.

Acommon finding in patients with chronic heart failure is exercise intolerance, which causes a progressive functional deterioration. 1 2 This vicious circle can be interrupted by discouraging a sedentary lifestyle and promoting physical activity. Controlled clinical studies have recently demonstrated that both in-hospital and home-based exercise training programs of various intensities induce favorable clinical effects by significantly increasing aerobic capacity, delaying the onset of anaerobic metabolism, reducing the sympathetic drive, and increasing the vagal tone. 3 4 5 6 7 Because peak V̇ o 2 is a good predictor of prognosis in patients with chronic heart failure, the improvement in exercise tolerance after exercise training may be associated with a more favorable outcome. Moreover, it is unclear whether improvements in myocardial perfusion and left ventricular function, recently demonstrated in animals 8 and humans Lucky Brand Latif Ab0uK
with ischemic heart disease after a short-term moderate exercise training program, can affect the clinical outcome.

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