Efficacy and safety of new-generation atrial antitachycardia pacing for atrial tachyarrhythmias in patients implanted with cardiac resynchronization therapy devices

Cost-effectiveness analyses to assess the value of reactive atrial-based anti-tachycardia pacing for patients with pacemakers and defibrillators: An Australian private healthcare system perspective

Background

Cardiac implantable electronic devices (CIED) with reactive atrial-based anti-tachycardia pacing (rATP) have been developed to stop the progression of atrial fibrillation (AF), a frequently occurring arrhythmia. This study assessed the value of rATP from the Australian private healthcare payer perspective.

Methods

A Markov state-transition model, including bradycardia, stroke, heart failure (HF), and death, was used to evaluate the value of rATP in conjunction with either pacemakers (PM), implantable cardioverter defibrillators (ICD), cardiac resynchronization therapy pacemakers (CRT-P), or CRT defibrillators (CRT-D). It was assumed that PM patients have bradycardia with no AF, and other patients have mild HF at insertion. Efficacy inputs, battery life, and device costs varied between devices. Conservatively, outpatient/follow-up costs of stroke and HF were excluded. All analyses were conducted using a cost-effectiveness threshold of 50 000 Australian dollars (A$) per quality-adjusted life year (QALY) gained, and deterministic sensitivity analysis was performed on key inputs.

Results

Using a 30-year horizon and a 5% discount rate, rATP was cost-effective up to a value of A$5609 (PM), A$11 628 (CRT-D), A$14 142 (CRT-P), and A$17 858 (ICD). In sensitivity analysis, varying patient age, rATP efficacy, HF and stroke mortality, stroke recurrence risk, utility values, time horizon, battery life, and the discount rate, the value of rATP ranged from A$3122 to A$11 375 (PM), A$1455 to A$26 409 (ICD), A$1171 to A$20 674 (CRT-P), and A$973 to A$16 907 (CRT-D).

Conclusion

Reactive ATP provides clinical benefits to patients who require a CIED. These benefits justify a value premium for devices with rATP functionality.

Characteristics of successful termination of atrial fibrillation by atrial antitachycardia pacing in patients with cardiac implantable electronic devices

Asymptomatic paroxysmal atrial fibrillation (AF) is often found in patients implanted with cardiac implantable electronic devices (CIEDs). Second-generation atrial antitachycardia pacing (A-ATP) is effective in managing AF in patients implanted with CIEDs. The purpose of this study was to evaluate the efficacy and safety of A-ATP in patients implanted with CIEDs. This was a single-center retrospective study involving 91 patients (male 46 patients, mean age 74 ± 9 years) implanted with Reactive A-ATP equipped devices (84 patients with pacemakers, 6 with ICDs, and 1 with a CRT-D). The AF burden, rate of AF termination, and details of the activation of the A-ATP were analyzed in each patient. During a mean follow-up period of 21 ± 13 months, A-ATP was activated in 45 of 91 patients (49.5%). No patients had adverse events. Although the efficacy of the A-ATP varied among the patients, the median rate of AF termination was 44%. In comparison to the A-ATP start time, "0 min" had a higher AF termination rate by the A-ATP (39.4% vs. 24.4%, P = 0.011). The rate of termination by the A-ATP was high for AF with a long cycle length and a relatively regular rhythm. A-ATP successfully terminated AF episodes in some patients implanted with CIEDs. The optimal settings of the A-ATP will be determined in future studies.

Cost-effectiveness analysis of cardiac implantable electronic devices with reactive atrial-based antitachycardia pacing

AIMS

Reactive atrial-based anti-tachycardia pacing (rATP) in pacemakers (PMs) and cardiac resynchronization therapy defibrillators (CRT-Ds) has been reported to prevent progression of atrial fibrillation, and this reduced progression is expected to decrease the risk of complications such as stroke and heart failure (HF). This study aimed to assess the cost-effectiveness of rATP in PMs and CRT-Ds in the Japanese public health insurance system.

METHODS AND RESULTS

We developed a Markov model comprising five states: bradycardia, post-stroke, mild HF, severe HF, and death. For devices with rATP and control devices without rATP, we compared the incremental cost-effectiveness ratio (ICER) from the payer's perspective. Costs were estimated from healthcare resource utilisation data in a Japanese claims database. We evaluated model uncertainty by analysing two scenarios for each device. The ICER was 763 729 JPY/QALY (5616 EUR/QALY) for PMs and 1,393 280 JPY/QALY (10 245 EUR/QALY) for CRT-Ds. In all scenarios, ICERs were below 5 million JPY/QALY (36 765 EUR/QALY), supporting robustness of the results.

CONCLUSION

According to a willingness to pay threshold of 5 million JPY/QALY, the devices with rATP were cost-effective compared with control devices without rATP, showing that the higher reimbursement price of the functional categories with rATP is justified from a healthcare economic perspective.

Prevention of long-lasting atrial fibrillation through antitachycardia pacing in DDDR pacemakers

OBJECTIVE

The MINERVA trial showed that in pacemaker patients with atrial fibrillation (AF) history, DDDRP pacing combining three algorithms - (a) atrial antitachycardia pacing with Reactive ATP enabled, (b) atrial preventive pacing and (c) managed ventricular pacing (MVP)-may effectively delay progression to persistent/permanent AF compared with standard DDDR pacing. We performed a comparative non-randomised evaluation to evaluate if Reactive ATP can be the main driver of persistent/permanent AF reduction independently on preventive pacing.

METHODS

Thirty-one centres included consecutive dual-chamber pacemaker patients with AF history. Reactive ATP was programmed in all patients while preventive atrial pacing was not enabled. These patients were compared with the three groups of MINERVA randomised trial (Control DDDR, MVP, and DDDRP). The main endpoint was the incidence of AF longer than 7 consecutive days.

RESULTS

A total of 146 patients (73 years old, 54% male) were included and followed for a median observation period of 31 months. The 2-year incidence of AF > 7 days was 12% in the Reactive ATP group, very similar to that found in the DDDRP arm of the MINERVA trial (13.8%, P = .732) and significantly lower than AF incidence found in the MINERVA Control DDDR arm (25.8%, P = .012) and in the MINERVA MVP arm (25.9%, P = .025).

CONCLUSIONS

In a real-world population of dual-chamber pacemaker patients with AF history, the use of Reactive ATP is associated with a low incidence of persistent AF, highlighting that the positive results of the MINERVA trial were related to the effectiveness of Reactive ATP rather than to preventive pacing.