Genetic testing in patients with acute coronary syndrome undergoing percutaneous coronary intervention: a cost-effectiveness analysis

Authors

  • A. LALA,

    1. Department of Medicine, Division of Cardiovascular Medicine, New York University School of Medicine
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    • These authors contributed equally to this work.

  • J. S. BERGER,

    1. Department of Medicine, Division of Cardiovascular Medicine, New York University School of Medicine
    2. Department of Medicine, Division of Hematology, New York University School of Medicine
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    • These authors contributed equally to this work.

  • G. SHARMA,

    1. Department of Medicine, Division of Cardiovascular Medicine, New York University School of Medicine
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  • J. S. HOCHMAN,

    1. Department of Medicine, Division of Cardiovascular Medicine, New York University School of Medicine
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  • R. SCOTT BRAITHWAITE,

    1. Department of Population Health, Section on Value and Effectiveness, New York University School of Medicine, New York, NY, USA
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  • J. A. LADAPO

    1. Department of Population Health, Section on Value and Effectiveness, New York University School of Medicine, New York, NY, USA
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Jeffrey S. Berger, Director of Cardiovascular Thrombosis, NYU Langone Medical Center, 530 First Avenue, SK 9R, New York, NY 10016, USA
Tel.: +1 212 263 4004; fax: +1 212 263 3988.
E-mail: jeffrey.berger@nyumc.org

Abstract

Summary.  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. Objectives:  We aimed to evaluate the cost-effectiveness of a CYP2C19*2 genotype-guided strategy of antiplatelet therapy in ACS patients undergoing PCI, compared with 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 per day. A generic estimate for clopidogrel of $1.00 per 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 with empiric clopidogrel, and $899 lower with a gain of 0.0005 QALY compared with empiric prasugrel. The strongest predictor of the preferred strategy was the relative risk of thrombotic events in carriers compared with 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.

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