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Assays have been developed to monitor on-P2Y12 platelet reactivity, and these tests can accurately predict which patients will have poor response to clopidogrel. We sought to determine the cost-effectiveness of using a platelet reactivity assay to aid in the selection between ticagrelor and clopidogrel based dual antiplatelet therapy in ACS patients.
A hybrid decision tree/Markov model was used to calculate 5 year costs (2011 US$), quality adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs) of 1 year of platelet reactivity assay-driven ticagrelor (given to patients with high platelet reactivity defined as >230 on the VerifyNow P2Y12 assay, Accumetrics, San Diego, CA, others got generic clopidogrel) or universal (given to all patients) ticagrelor. We assumed a cohort of 65 year old ACS patients and 32% and 13% incidences of high platelet reactivity at discharge and at 1 month. The analysis was conducted from a US payer perspective and used a 1 year cycle length. Data depicting the efficacy and safety of ticagrelor and clopidogrel were taken from multinational randomized trials.
Patients experiencing an acute coronary event treated with ticagrelor or clopidogrel based upon the results of the platelet reactivity assay lived an average of 3.497 QALYs at a treatment cost of $30,615. Those receiving universal ticagrelor lived an average of 3.530 QALYs and incurred costs of $32,865 (ICER for universal ticagrelor= $68,182/QALY). Universal ticagrelor was not cost-effective unless the yearly cost of ticagrelor was <$2,800, the yearly cost of clopidogrel rose above $1,100 or the hazard ratio for death on ticagrelor vs. clopidogrel was <0.74. Monte Carlo simulation suggested universal and platelet reactivity assay-driven selection of ticagrelor would have ICERs<$50,000/QALY (be cost-effective) in 26% and 74% of 10,000 iterations, respectively.
Universal ticagrelor was not cost-effective compared to platelet reactivity assay-driven use of ticagrelor or clopidogrel. In the age of generic clopidogrel, assay-driven selection of antiplatelet therapy appears to be a reasonable strategy to decrease ACS associated healthcare costs.
- 2013 American College of Cardiology Foundation