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CLINICAL RESEARCH: PLATELET INHIBITION

The Role of Risk Stratification in the Decision to Provide Upstream Versus Selective Glycoprotein IIb/IIIa Inhibitors for Acute Coronary Syndromes

A Cost-Effectiveness Analysis

Ruchira Glaser, MD^_*,_*, Henry A. Glick, PhD, Howard C. Herrmann, MD, FACC^_* and Stephen E. Kimmel, MD, MSCE, FACC^_*,

^_* Division of Cardiovascular Medicine, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
Center for Clinical Epidemiology and Biostatistics and Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.

Manuscript received December 3, 2004; revised manuscript received July 22, 2005, accepted August 23, 2005.

^_* Reprint requests and correspondence: Dr. Ruchira Glaser, University of Pennsylvania School of Medicine, Medicine-Cardiology, 9 Founders Cardiology-HUP, 3400 Spruce Street, Philadelphia, Pennsylvania 19104. (Email: ruchira.glaser{at}uphs.upenn.edu).

OBJECTIVES: We endeavored to determine under what conditions a strategy of upstream use of small molecule platelet glycoprotein (GP) IIb/IIIa inhibitors for all acute coronary syndromes (ACS) patients is cost effective compared to that of selective use of abciximab in only those patients requiring percutaneous coronary intervention (PCI).

BACKGROUND: Small molecule GP IIb/IIIa inhibitors have shown benefit in ACS, but abciximab, the more expensive GP IIb/IIIa inhibitor, may be more effective during PCI. However, abciximab does not have proven efficacy in medical management. No prior study has attempted to balance these competing benefits.

METHODS: A decision analysis was performed to examine two strategies: 1) treat all ACS patients upstream with a small molecule GP IIb/IIIa inhibitor and continue through medical management and PCI, if performed; or 2) wait, and selectively use abciximab only in patients who ultimately undergo PCI. Applicable randomized controlled trial data were used for the principal analysis.

RESULTS: The strategy of upstream use of a small molecule GP IIb/IIIa inhibitor was superior to selective use, and economically acceptable, with a cost-effectiveness ratio of $18,000 per year of life gained. The superiority of the upstream use strategy persisted over the majority of sensitivity analyses. When stratified by risk according to Thrombolysis in Myocardial Infarction risk score, a strategy of upstream use was only cost effective in those patients with moderate or high risk.

CONCLUSIONS: Upstream use of small molecule GP IIb/IIIa inhibition in ACS patients with moderate or high risk for cardiovascular events is a cost-effective approach that should be considered in this subset of patients.

Abbreviations and Acronyms   ACS = acute coronary syndromes   CABG = coronary artery bypass graft   GP = glycoprotein   ICER = incremental cost-effectiveness ratio   MI = myocardial infarction   OR = odds ratio   PCI = percutaneous coronary intervention   QALY = quality-adjusted life years   RR = relative risk   TACTICS = Treat angina with Aggrastat and determine Cost of Therapy with Invasive or Conservative Strategy

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