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Andò G, Lombardo L, Alagna G, Micari A, Francaviglia B, Cascone A, Capranzano P. Monotherapy with P2Y 12-inhibitors after dual antiplatelet therapy: Filling gaps in evidence. Int J Cardiol 2024; 401:131893. [PMID: 38382856 DOI: 10.1016/j.ijcard.2024.131893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 02/13/2024] [Accepted: 02/18/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND Whether P2Y12 inhibitor monotherapy (P2Y12-I) is superior to aspirin following DAPT discontinuation post-PCI remains to be established. METHODS We updated our prior network meta-analysis where P2Y12-I and aspirin had been compared with DAPT or directly with each other. The focus is specifically on the available direct evidence, now consisting of the three head-to-head comparisons of P2Y12-I and aspirin in event-free PCI patients after DAPT. We include a Trial Sequential Analysis of the direct evidence based on meta-analytical literature. RESULTS The main finding reveals a 39% significantly lower risk of myocardial infarction with P2Y12-I (RR 0.61, 95% CI 0.47-0.78, p = 0.0001, I2 = 0%) with no difference in bleeding. Trial Sequential Analysis demonstrates clinically meaningful evidence for a reduction in the incidence of myocardial infarction with P2Y12-I that is also supported by statistical significance. CONCLUSIONS Accruing data highlight that P2Y12-I following DAPT discontinuation after PCI is associated with lower risk for MI and a similar risk for bleeding as compared with ASA. In light of potential limitations to the widespread adoption of life-long P2Y12-I treatment, clinicians should consider identifying selected patients who are expected to derive the highest benefit.
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Affiliation(s)
- Giuseppe Andò
- Department of Clinical and Experimental Medicine, University of Messina and Azienda Ospedaliera Universitaria Policlinico "Gaetano Martino", Messina, Italy.
| | - Luca Lombardo
- Division of Cardiology, University of Catania and Azienda Ospedaliera Universitaria Policlinico "Gaspare Rodolico", Catania, Italy
| | - Giulia Alagna
- Department of Clinical and Experimental Medicine, University of Messina and Azienda Ospedaliera Universitaria Policlinico "Gaetano Martino", Messina, Italy
| | - Antonino Micari
- Department of Clinical and Experimental Medicine, University of Messina and Azienda Ospedaliera Universitaria Policlinico "Gaetano Martino", Messina, Italy
| | - Bruno Francaviglia
- Division of Cardiology, University of Catania and Azienda Ospedaliera Universitaria Policlinico "Gaspare Rodolico", Catania, Italy
| | - Alessia Cascone
- Department of Clinical and Experimental Medicine, University of Messina and Azienda Ospedaliera Universitaria Policlinico "Gaetano Martino", Messina, Italy
| | - Piera Capranzano
- Division of Cardiology, University of Catania and Azienda Ospedaliera Universitaria Policlinico "Gaspare Rodolico", Catania, Italy
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Hong D, Lee J, Lee H, Cho J, Guallar E, Choi KH, Lee SH, Shin D, Lee JY, Lee SJ, Lee SY, Kim SM, Yun KH, Cho JY, Kim CJ, Ahn HS, Nam CW, Yoon HJ, Park YH, Lee WS, Park TK, Yang JH, Choi SH, Gwon HC, Song YB, Hahn JY, Kang D, Lee JM. Cost-Effectiveness of Intravascular Imaging-Guided Complex PCI: Prespecified Analysis of RENOVATE-COMPLEX-PCI Trial. Circ Cardiovasc Qual Outcomes 2024; 17:e010230. [PMID: 38477162 DOI: 10.1161/circoutcomes.123.010230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 11/30/2023] [Indexed: 03/14/2024]
Abstract
BACKGROUND Although clinical benefits of intravascular imaging-guided percutaneous coronary intervention (PCI) in patients with complex coronary artery lesions have been observed in previous trials, the cost-effectiveness of this strategy is uncertain. METHODS RENOVATE-COMPLEX-PCI (Randomized Controlled Trial of Intravascular Imaging Guidance vs Angiography-Guidance on Clinical Outcomes After Complex Percutaneous Coronary Intervention) was conducted in Korea between May 2018 and May 2021. This prespecified cost-effectiveness substudy was conducted using Markov model that simulated 3 states: (1) post-PCI, (2) spontaneous myocardial infarction, and (3) death. A simulated cohort was derived from the intention-to-treat population, and input parameters were extracted from either the trial data or previous publications. Cost-effectiveness was evaluated using time horizon of 3 years (within trial) and lifetime. The primary outcome was incremental cost-effectiveness ratio (ICER), an indicator of incremental cost on additional quality-adjusted life years (QALYs) gained, in intravascular imaging-guided PCI compared with angiography-guided PCI. The current analysis was performed using the Korean health care sector perspective with reporting the results in US dollar (1200 Korean Won, ₩=1 dollar, $). Willingness to pay threshold was $35 000 per QALY gained. RESULTS A total of 1639 patients were included in the trial. During 3-year follow-up, medical costs ($8661 versus $7236; incremental cost, $1426) and QALY (2.34 versus 2.31; incremental QALY, 0.025) were both higher in intravascular imaging-guided PCI than angiography-guided PCI, resulting incremental cost-effectiveness ratio of $57 040 per QALY gained within trial data. Conversely, lifetime simulation showed total cumulative medical cost was reversed between the 2 groups ($40 455 versus $49 519; incremental cost, -$9063) with consistently higher QALY (8.24 versus 7.89; incremental QALY, 0.910) in intravascular imaging-guided PCI than angiography-guided PCI, resulting in a dominant incremental cost-effectiveness ratio. Consistently, 70% of probabilistic iterations showed cost-effectiveness of intravascular imaging-guided PCI in probabilistic sensitivity analysis. CONCLUSIONS The current cost-effectiveness analysis suggests that imaging-guided PCI is more cost-effective than angiography-guided PCI by reducing medical cost and increasing quality-of-life in complex coronary artery lesions in long-term follow-up. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03381872.
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Affiliation(s)
- David Hong
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (D.H., K.H.C., T.K.P., J.H.Y., S.-H.C., H.-C.G., Y.B.S., J.-Y.H., J.M.L.)
| | - Jin Lee
- Center for Clinical Epidemiology, Samsung Medical Center, Sungkyunkwan University, Seoul, South Korea (J.L., J.C., D.K.)
- Department of Clinical Research Design and Evaluation, SAIHST, Sungkyunkwan University, Seoul, South Korea (J.L., J.C., D.K.)
| | - Hankil Lee
- College of Pharmacy, Ajou University, Suwon, South Korea (H.L.)
| | - Juhee Cho
- Center for Clinical Epidemiology, Samsung Medical Center, Sungkyunkwan University, Seoul, South Korea (J.L., J.C., D.K.)
- Department of Clinical Research Design and Evaluation, SAIHST, Sungkyunkwan University, Seoul, South Korea (J.L., J.C., D.K.)
| | - Eliseo Guallar
- Department of Epidemiology and Medicine, and Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD (E.G.)
| | - Ki Hong Choi
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (D.H., K.H.C., T.K.P., J.H.Y., S.-H.C., H.-C.G., Y.B.S., J.-Y.H., J.M.L.)
| | - Seung Hun Lee
- Chonnam National University Hospital, Gwangju, Korea (S.H.L.)
| | - Doosup Shin
- Division of Cardiology, Department of Internal Medicine, Duke University Medical Center, Durham, NC (D.S.)
| | - Jong-Young Lee
- Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (J.-Y.L., S.-J.L.)
| | - Seung-Jae Lee
- Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (J.-Y.L., S.-J.L.)
| | - Sang Yeub Lee
- Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea (S.Y.L., S.M.K.)
- Chung-Ang University College of Medicine, Chung-Ang University Gwangmyeong Hospital, Korea (S.Y.L.)
| | - Sang Min Kim
- Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea (S.Y.L., S.M.K.)
| | - Kyeong Ho Yun
- Wonkwang University Hospital, Iksan, Korea (K.H.Y., J.Y.C.)
| | - Jae Young Cho
- Wonkwang University Hospital, Iksan, Korea (K.H.Y., J.Y.C.)
| | - Chan Joon Kim
- The Catholic University of Korea, Uijeongbu St. Mary's Hospital, Seoul, Korea (C.J.K., H.-S.A.)
| | - Hyo-Suk Ahn
- The Catholic University of Korea, Uijeongbu St. Mary's Hospital, Seoul, Korea (C.J.K., H.-S.A.)
| | - Chang-Wook Nam
- Keimyung University Dongsan Hospital, Daegu, Korea (C.-W.N., H.-J.Y.)
| | - Hyuck-Jun Yoon
- Keimyung University Dongsan Hospital, Daegu, Korea (C.-W.N., H.-J.Y.)
| | - Yong Hwan Park
- Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Korea (Y.H.P.)
| | - Wang Soo Lee
- Chung-Ang University College of Medicine, Chung-Ang University Hospital, Seoul, Korea (W.S.L.)
| | - Taek Kyu Park
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (D.H., K.H.C., T.K.P., J.H.Y., S.-H.C., H.-C.G., Y.B.S., J.-Y.H., J.M.L.)
| | - Jeong Hoon Yang
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (D.H., K.H.C., T.K.P., J.H.Y., S.-H.C., H.-C.G., Y.B.S., J.-Y.H., J.M.L.)
| | - Seung-Hyuk Choi
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (D.H., K.H.C., T.K.P., J.H.Y., S.-H.C., H.-C.G., Y.B.S., J.-Y.H., J.M.L.)
| | - Hyeon-Cheol Gwon
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (D.H., K.H.C., T.K.P., J.H.Y., S.-H.C., H.-C.G., Y.B.S., J.-Y.H., J.M.L.)
| | - Young Bin Song
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (D.H., K.H.C., T.K.P., J.H.Y., S.-H.C., H.-C.G., Y.B.S., J.-Y.H., J.M.L.)
| | - Joo-Yong Hahn
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (D.H., K.H.C., T.K.P., J.H.Y., S.-H.C., H.-C.G., Y.B.S., J.-Y.H., J.M.L.)
| | - Danbee Kang
- Center for Clinical Epidemiology, Samsung Medical Center, Sungkyunkwan University, Seoul, South Korea (J.L., J.C., D.K.)
- Department of Clinical Research Design and Evaluation, SAIHST, Sungkyunkwan University, Seoul, South Korea (J.L., J.C., D.K.)
| | - Joo Myung Lee
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (D.H., K.H.C., T.K.P., J.H.Y., S.-H.C., H.-C.G., Y.B.S., J.-Y.H., J.M.L.)
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4
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Hong D, Lee SH, Lee J, Lee H, Shin D, Kim HK, Park KH, Choo EH, Kim CJ, Kim MC, Hong YJ, Jeong MH, Ahn SG, Doh JH, Lee SY, Don Park S, Lee HJ, Kang MG, Koh JS, Cho YK, Nam CW, Choi KH, Park TK, Yang JH, Song YB, Choi SH, Gwon HC, Guallar E, Cho J, Hahn JY, Kang D, Lee JM. Cost-Effectiveness of Fractional Flow Reserve-Guided Treatment for Acute Myocardial Infarction and Multivessel Disease: A Prespecified Analysis of the FRAME-AMI Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2352427. [PMID: 38270954 PMCID: PMC10811558 DOI: 10.1001/jamanetworkopen.2023.52427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 11/14/2023] [Indexed: 01/26/2024] Open
Abstract
Importance Complete revascularization by non-infarct-related artery (IRA) percutaneous coronary intervention (PCI) in patients with acute myocardial infarction is standard practice to improve patient prognosis. However, it is unclear whether a fractional flow reserve (FFR)-guided or angiography-guided treatment strategy for non-IRA PCI would be more cost-effective. Objective To evaluate the cost-effectiveness of FFR-guided compared with angiography-guided PCI in patients with acute myocardial infarction and multivessel disease. Design, Setting, and Participants In this prespecified cost-effectiveness analysis of the FRAME-AMI randomized clinical trial, patients were randomly allocated to either FFR-guided or angiography-guided PCI for non-IRA lesions between August 19, 2016, and December 24, 2020. Patients were aged 19 years or older, had ST-segment elevation myocardial infarction (STEMI) or non-STEMI and underwent successful primary or urgent PCI, and had at least 1 non-IRA lesion (diameter stenosis >50% in a major epicardial coronary artery or major side branch with a vessel diameter of ≥2.0 mm). Data analysis was performed on August 27, 2023. Intervention Fractional flow reserve-guided vs angiography-guided PCI for non-IRA lesions. Main Outcomes and Measures The model simulated death, myocardial infarction, and repeat revascularization. Future medical costs and benefits were discounted by 4.5% per year. The main outcomes were quality-adjusted life-years (QALYs), direct medical costs, incremental cost-effectiveness ratio (ICER), and incremental net monetary benefit (INB) of FFR-guided PCI compared with angiography-guided PCI. State-transition Markov models were applied to the Korean, US, and European health care systems using medical cost (presented in US dollars), utilities data, and transition probabilities from meta-analysis of previous trials. Results The FRAME-AMI trial randomized 562 patients, with a mean (SD) age of 63.3 (11.4) years. Most patients were men (474 [84.3%]). Fractional flow reserve-guided PCI increased QALYs by 0.06 compared with angiography-guided PCI. The total cumulative cost per patient was estimated as $1208 less for FFR-guided compared with angiography-guided PCI. The ICER was -$19 484 and the INB was $3378, indicating that FFR-guided PCI was more cost-effective for patients with acute myocardial infarction and multivessel disease. Probabilistic sensitivity analysis showed consistent results and the likelihood iteration of cost-effectiveness in FFR-guided PCI was 97%. When transition probabilities from the pairwise meta-analysis of the FLOWER-MI and FRAME-AMI trials were used, FFR-guided PCI was more cost-effective than angiography-guided PCI in the Korean, US, and European health care systems, with an INB of $3910, $8557, and $2210, respectively. In probabilistic sensitivity analysis, the likelihood iteration of cost-effectiveness with FFR-guided PCI was 85%, 82%, and 31% for the Korean, US, and European health care systems, respectively. Conclusions and Relevance This cost-effectiveness analysis suggests that FFR-guided PCI for non-IRA lesions saved medical costs and increased quality of life better than angiography-guided PCI for patients with acute myocardial infarction and multivessel disease. Fractional flow reserve-guided PCI should be considered in determining the treatment strategy for non-IRA stenoses in these patients. Trial Registration ClinicalTrials.gov Identifier: NCT02715518.
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Affiliation(s)
- David Hong
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Hun Lee
- Chonnam National University Hospital, Gwangju, Korea
| | - Jin Lee
- Center for Clinical Epidemiology, Samsung Medical Center, Sungkyunkwan University, Seoul, South Korea
- Department of Clinical Research Design and Evaluation, Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University, Seoul, South Korea
| | - Hankil Lee
- College of Pharmacy, Ajou University, Suwon, South Korea
| | - Doosup Shin
- Division of Cardiology, Department of Internal Medicine, Duke University Medical Center, Durham, North Carolina
| | - Hyun Kuk Kim
- Chosun University Hospital, University of Chosun College of Medicine, Gwangju, Korea
| | - Keun Ho Park
- Chosun University Hospital, University of Chosun College of Medicine, Gwangju, Korea
| | - Eun Ho Choo
- Seoul St Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Chan Joon Kim
- Uijeongbu St Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Min Chul Kim
- Chonnam National University Hospital, Gwangju, Korea
| | | | | | - Sung Gyun Ahn
- Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital, Wonju, Korea
| | - Joon-Hyung Doh
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Sang Yeub Lee
- Chung-Ang University College of Medicine, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, Korea
| | | | | | - Min Gyu Kang
- Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Jin-Sin Koh
- Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Yun-Kyeong Cho
- Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Chang-Wook Nam
- Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Ki Hong Choi
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Taek Kyu Park
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Hoon Yang
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Bin Song
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung-Hyuk Choi
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyeon-Cheol Gwon
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eliseo Guallar
- Department of Epidemiology and Medicine, Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Juhee Cho
- Center for Clinical Epidemiology, Samsung Medical Center, Sungkyunkwan University, Seoul, South Korea
- Department of Clinical Research Design and Evaluation, Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University, Seoul, South Korea
| | - Joo-Yong Hahn
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Danbee Kang
- Center for Clinical Epidemiology, Samsung Medical Center, Sungkyunkwan University, Seoul, South Korea
- Department of Clinical Research Design and Evaluation, Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University, Seoul, South Korea
| | - Joo Myung Lee
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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