LAA Closure Edges Out Medical Therapy for Cost-effectiveness in AF
Transcatheter left atrial appendage (LAA) occlusion is more cost-effective than numerous pharmacologic strategies for stroke prevention in patients with nonvalvular atrial fibrillation (AF), according to a modeling study presented at TCT 2014.
Vivian W. Lee, BSc, PharmD, of the Chinese University of Hong Kong, and colleagues used a Markov model to compare LAA closure with seven different medical therapy strategies. The model simulated a cohort of 65-year-old patients with nonvalvular AF moving between different health statuses in cycles of 1 year.
Cost-effectiveness in terms of incremental cost-effectiveness ratio (ICER) per quality-adjusted life year (QALY) favored LAA closure over almost all pharmacological strategies (see Table).
Additionally, LAA closure emerged as the preferred therapy in a one-way sensitivity analysis varied by HAS-BLED score and time horizons of 5, 10, 15 and 20 years.
The health states in the model included AF without event, with previous event and with ischemic cerebrovascular events, hemorrhage, MI and vascular or nonvascular events. Data on efficacy were derived from several previously published clinical trials, including ACTIVE, RE-LY, PROTECT AF and PREVAIL.
According to Lee, the better cost-effectiveness of LAA closure compared with medical therapy is not surprising because anticoagulant use can be accompanied by issues like overdosing and noncompliance that may lead to costly complications. “As a clinical pharmacist, I see patients struggling with drug-related problems every day,” she said in an interview with TCT Daily. “LAA [occlusion] will have fewer issues since patients will only require daily aspirin therapy after the 45 days of warfarin therapy.” She added that patients with high thrombotic and bleeding risks in particular would be ideal candidates for closure.
Lee also noted that while some may cite a lack of long-term data as a limitation of LAA closure, PROTECT AF demonstrated superiority at 4 years for closure compared with warfarin. In that trial, the Watchman device (Boston Scientific) yielded a nearly 40% RR reduction in the primary composite endpoint of stroke, systemic embolism and cardiovascular or unexplained death.
Note: The 110-mg dose of dabigatran is not approved by the US Food and Drug Administration.
- Lee reports support from Boehringer Ingelheim.