a1 McGill University and McGill University Health Center
a2 McGill University Health Centre
a3 Radboud University Nijmegen Medical Center
a4 McGill University and McGill University Health Centre
Objectives: Implantable cardioverter defibrillators (ICDs) are an effective but expensive treatment for the prevention of sudden cardiac deaths in patients with severe left-ventricular dysfunction. Recent studies suggest that microvolt T-wave alternans (MTWA) predicts mortality and severe arrhythmic events in this population. However, the impact of MTWA on ICD cost-effectiveness is unknown.
Methods: A Markov decision-analysis model evaluated three treatment strategies for primary prevention in patients with severe left-ventricular dysfunction: (i) medical therapy for all; (ii) ICD therapy for all; and (iii) selective ICD therapy based on non-negative (positive or indeterminate) MTWA test results. Incremental cost-effectiveness ratios (ICER) were calculated from the perspective of a third party payer using a 10-year time horizon. Sensitivity analyses examined the robustness of the estimates.
Results: A treatment strategy involving ICD therapy in all patients was associated with an ICER of $121,800/quality-adjusted life-year (QALY) compared with medical therapy, whereas a treatment strategy involving the selective use of ICDs based on MTWA test results was associated with an ICER of $108,900/QALY compared with medical therapy. Sensitivity analyses suggest that, under most scenarios, the selective use of ICDs based on MTWA results does not decrease the ICER to below $100,000/QALY.
Conclusion: MTWA only marginally improves the cost-effectiveness of ICDs for primary prevention in patients with severe left-ventricular dysfunction. There remains a need for improved means to effectively identify which patients will derive the greatest benefit from ICD implantation.
J.M.B. conceived of the study idea, and K.B.F., X.X., and J.M.B. contributed to the study design. K.B.F. and X.X. drafted the manuscript. X.X. conducted the statistical analyses. All authors were involved in revising the article for important intellectual content, interpreting the data, and approved the final version to be published. Drs. Dendukuri and Brophy receive financial support from le Fonds de la Recherche en Santé du Québec. Mr. Filion receives financial support from the Faculty of Medicine of McGill University, the Research Institute of the McGill University Health Centre, and the Department of Medicine of the McGill University Health Centre. Ms. van der Avoort received financial support from the Foundation of the University of Nijmegen and the Faculty of Medicine of the Radboud University Nijmegen Medical Center. The authors have no competing interests to declare.