Genetic Testing in Patients with Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention: A Cost-Effectiveness Analysis.

Lala A, Berger JS, Sharma G, Hochman JS, Scott Braithwaite R, Ladapo JA.

Source

Department of Medicine, Division of Cardiovascular Medicine, New York University School of Medicine, New York, NY Department of Medicine, Division of Hematology, New York University School of Medicine, New York, NY Department of Medicine, Division of General Internal Medicine, Section of Value and Effectiveness, New York University School of Medicine, New York, NY.

Abstract

Background: The CYP2C19 genotype is a predictor of adverse cardiovascular events in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI) treated with clopidogrel. Objective: We aimed to evaluate the cost-effectiveness of a CYP2C19*2 genotype-guided strategy of antiplatelet therapy in ACS patients undergoing PCI, compared to two "no testing" strategies (empiric clopidogrel or prasugrel). Methods: We developed a Markov model to compare three strategies. The model captured adverse cardiovascular events and antiplatelet-related complications. Costs were expressed in 2010 US dollars and estimated using diagnosis-related group codes and Medicare reimbursement rates. The net wholesale price for prasugrel was estimated as $5.45/day. A generic estimate for clopidogrel of $1.00/day was used, and genetic testing was assumed to cost $500. Results: Base case analyses demonstrated little difference between treatment strategies. The genetic testing-guided strategy yielded the most QALYs and was the least costly. Over 15 months, total costs were $18 lower with a gain of 0.004 QALY in the genotype-guided strategy compared to empiric clopidogrel, and $899 lower with a gain of 0.0005 QALY compared to empiric prasugrel. The strongest predictor of the preferred strategy was the relative risk of thrombotic events in carriers compared to wild-type individuals treated with clopidogrel. Above a 47% increased risk, a genotype-guided strategy was the dominant strategy. Above a clopidogrel cost of $3.96 per day, genetic testing was no longer dominant but remained cost-effective. Conclusions: Among ACS patients undergoing PCI, a genotype-guided strategy yields similar outcomes to empiric approaches to treatment, but is marginally less costly and more effective. © 2012 International Society on Thrombosis and Haemostasis.
© 2012 International Society on Thrombosis and Haemostasis.