Skip to main content
SpringerLink
Log in

Cost Effectiveness of Treatments for non-ST-segment elevation Acute Coronary Syndrome

  • Systematic Review
  • Published:
PharmacoEconomics Aims and scope Submit manuscript

Abstract

Background

Acute coronary syndrome (ACS) represents the most common subset of cardiovascular heart diseases and relates to high rates of morbidity and mortality worldwide and, consequently, to both the direct and indirect costs to the health system and society. Given the rising healthcare costs combined with budgetary constraints, health care systems and decision makers are faced with challenging decisions and the need to choose alternative treatments that not only improve patient quantity and quality of life but are also economically attractive.

Objectives

To systematically review the published literature and to identify studies evaluating the cost effectiveness of different treatments for patients presenting with non-ST-segment elevation (NSTE) ACS.

Data Sources

A literature search was performed using PubMed and the Cochrane Library until October 2013, with no limit on publication date.

Study Selection

The search was conducted using predetermined inclusion and exclusion criteria, limiting articles to those published in the English language and those reporting results of economic evaluations [i.e. cost-effectiveness (CEA), cost-utility (CUA) cost-minimisation (CMA) cost-consequence (CCA) and cost-benefit (CBA) analyses] of the different treatment therapies used for managing patients presenting with NSTE-ACS. Publications such as editorials, letters to the editor, posters, expert opinions, reviews, systematic reviews, or meta-analyses were excluded.

Study Appraisal Methods

All studies included were assessed for their methodological quality using the British Medical Journal checklist.

Results

A total of 39 studies were included, presenting a wide variation in terms of methodological approaches and settings, thus resulting in different ranges of incremental cost-effectiveness ratios for each treatment evaluated.

Conclusions

Evidence from the present systematic review suggests that the majority of the available treatments represent either cost-saving or cost-effective options for NSTE-ACS patients. Moreover, the cost effectiveness of the available treatments was found to be dependent on various factors, particularly the risk profile of patients and the cost of treatment, and hence there is a need to take these into consideration when making decisions and choices.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Hamm CW, et al. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: the Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2011;32(23):2999–3054.

    Article  PubMed  Google Scholar 

  2. Turpie AG. Burden of disease: medical and economic impact of acute coronary syndromes. Am J Manag Care. 2006;12(16 Suppl):S430–4.

    PubMed  Google Scholar 

  3. Lee CH, Wong P. Acute coronary syndrome: from epidemiology to treatment. Ann Acad Med. 2010;39(3):161–2.

    Google Scholar 

  4. Chang H, et al. Non-ST-segment elevation acute coronary syndromes: targeted imaging to refine upstream risk stratification. Circ Cardiovasc Imaging. 2012;5(4):536–46.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Braunwald E. Unstable angina and non-ST elevation myocardial infarction. Am J Respir Crit Care Med. 2012;185(9):924–32.

    Article  PubMed  CAS  Google Scholar 

  6. Anderson JL, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 2002 guidelines for the management of patients with unstable angina/non ST-elevation myocardial infarction): developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons: endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. Circulation. 2007;116(7):e148–304.

    Article  PubMed  Google Scholar 

  7. Moher D, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med. 2009;151(4):264–9 (W64).

    Article  PubMed  Google Scholar 

  8. Drummond MF, Jefferson TO. Guidelines for authors and peer reviewers of economic submissions to the BMJ. The BMJ Economic Evaluation Working Party. BMJ. 1996;313(7052):275–83.

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  9. Jefferson T, et al. Evaluating the BMJ guidelines for economic submissions: prospective audit of economic submissions to BMJ and The Lancet. JAMA. 1998;280(3):275–7.

    Article  PubMed  CAS  Google Scholar 

  10. Badia X, et al. Short- and long-term cost-effectiveness analysis of adding clopidogrel to standard therapy in acute coronary syndrome patients in Spain. Rev Esp Cardiol. 2005;58:1385–95.

    Article  Google Scholar 

  11. Brown R, Armstrong P. Cost effectiveness in Canada of eptifibatide treatment for acute coronary syndrome patients using PURSUIT subgroup analysis. Can J Cardiol. 2003;19(2):161–6.

    PubMed  Google Scholar 

  12. Brown RE, et al. Cost effectiveness of eptifibatide in acute coronary syndromes; an economic analysis of Western European patients enrolled in the PURSUIT trial. The Platelet IIa/IIb in unstable angina: receptor suppression using integrilin therapy. Eur Heart J. 2002;23(1):50–8.

    Article  PubMed  CAS  Google Scholar 

  13. Bruggenjurgen B, et al. Long-term cost-effectiveness of clopidogrel in patients with acute coronary syndrome without ST-segment elevation in Germany. Eur J Health Econ. 2007;8:51–7.

    Article  PubMed  CAS  Google Scholar 

  14. Davies A, et al. Prasugrel vs clopidogrel in patients with acute coronary syndrome undergoing percutaneous coronary intervention: a model-based cost-effectiveness analysis for Germany, Sweden, the Netherlands, and Turkey. J Med Econ. 2013;16(4):510–21.

    Article  PubMed  Google Scholar 

  15. Davies A, et al. Prasugrel compared to clopidogrel in patients with acute coronary syndrome undergoing percutenaous coronary intervention: a Spanish model-based cost effectiveness analysis. Farm Hosp. 2013;37(4):307–16.

    PubMed  CAS  Google Scholar 

  16. Frei A, Lindgren P, Meier B. Cost-effectiveness of clopidogrel in patients with acute coronary syndrome in Switzerland. Kardiovask Med. 2004;7:174–80.

    Google Scholar 

  17. Karnon J, et al. A cost-utility analysis of clopidogrel in patients with non-ST-segment-elevation acute coronary syndromes in the UK. Int J Cardiol. 2006;109:307–16.

    Article  PubMed  CAS  Google Scholar 

  18. Kolm P, et al. Cost-effectiveness of clopidogrel in acute coronary syndromes in Canada: a long-term analysis based on the CURE trial. Can J Cardiol. 2007;23(13):1037–42.

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  19. Kourlaba G, Fragoulakis V, Maniadakis N. Economic evaluation of clopidogrel in acute coronary syndrome patients without ST-segment elevation in Greece: a cost-utility analysis. Appl Health Econ Health Policy. 2012;10(4):261–71.

    Article  PubMed  Google Scholar 

  20. Lamy A, et al. The cost-effectiveness of the use of clopidogrel in acute coronary syndromes in five countries based upon the CURE study. Eur J Cardiovasc Prev Rehabil. 2004;11:460–5.

    PubMed  Google Scholar 

  21. Latour-Perez J, et al. Using triple antiplatelet therapy in patients with non-ST elevation acute coronary syndrome managed invasively: a cost-effectiveness analysis. Value Health. 2008;11(5):853–61.

    Article  PubMed  Google Scholar 

  22. Latour-Perez J, et al. Using clopidogrel in non-ST-segment elevation acute coronary syndrome patients: a cost-utility analysis in Spain. Value Health. 2004;7(1):52–60.

    Article  PubMed  Google Scholar 

  23. Lindgren P, Jonsson B, Yusuf S. Cost-effectiveness of clopidogrel in acute coronary syndromes in Sweden: a long-term model based on the CURE trial. J Intern Med. 2004;255(5):562–70.

    Article  PubMed  CAS  Google Scholar 

  24. Lindgren P, et al. The long-term cost-effectiveness of clopidogrel plus aspirin in patients undergoing percutaneous coronary intervention in Sweden. Clin Ther. 2005;27(1):100–10.

    Article  PubMed  CAS  Google Scholar 

  25. Mahoney EM, et al. Long-term cost-effectiveness of early and sustained clopidogrel therapy for up to 1 year in patients undergoing percutaneous coronary intervention after presenting with acute coronary syndromes without ST-segment elevation. Am Heart J. 2006;151:219–27.

    Article  PubMed  CAS  Google Scholar 

  26. Mahoney EM, et al. Cost-effectiveness of prasugrel versus clopidogrel in patients with acute coronary syndromes and planned percutaneous coronary intervention: results from the trial to assess improvement in therapeutic outcomes by optimizing platelet inhibition with prasugrel-thrombolysis in myocardial infarction TRITON-TIMI 38. Circulation. 2010;121:71–9.

    Article  PubMed  Google Scholar 

  27. Mark DB, et al. Cost-effectiveness of platelet glycoprotein IIb/IIIa inhibition with eptifibatide in patients with non-ST-elevation acute coronary syndromes. Circulation. 2000;101(4):366–71.

    Article  PubMed  CAS  Google Scholar 

  28. Mauskopf JA, et al. Cost-effectiveness of prasugrel in a US managed care population. J Med Econ. 2012;15:166–74.

    Article  PubMed  Google Scholar 

  29. Nikolic E, et al. Cost-effectiveness of treating acute coronary syndrome patients with ticagrelor for 12 months: results from the PLATO study. Eur Heart J. 2013;34(3):220–8.

    Article  PubMed  Google Scholar 

  30. Schleinitz MD, Heidenreich PA. A cost-effectiveness analysis of combination antiplatelet therapy for high-risk acute coronary syndromes: clopidogrel plus aspirin versus aspirin alone. Ann Intern Med. 2005;142(4):251–9.

    Article  PubMed  CAS  Google Scholar 

  31. Szucs TD, Meyer BJ, Kiowski W. Economic assessment of tirofiban in the management of acute coronary syndromes in the hospital setting: an analysis based on the PRISM PLUS trial. Eur Heart J. 1999;20(17):1253–60.

    Article  PubMed  CAS  Google Scholar 

  32. Weintraub WS, et al. Long-term cost-effectiveness of clopidogrel given for up to one year in patients with acute coronary syndromes without ST-segment elevation. J Am Coll Cardiol. 2005;45(6):838–45.

    Article  PubMed  CAS  Google Scholar 

  33. Theidel U, et al. Cost-effectiveness of ticagrelor versus clopidogrel for the prevention of atherothrombotic events in adult patients with acute coronary syndrome in Germany. Clin Res Cardiol. 2013;102(6):447–58.

    Article  PubMed  Google Scholar 

  34. Balen RM, et al. Cost-effectiveness analysis of enoxaparin versus unfractionated heparin for acute coronary syndromes: a Canadian hospital perspective. Pharmacoeconomics. 1999;16:533–42.

    Article  PubMed  CAS  Google Scholar 

  35. Brosa M, et al. Cost-effectiveness analysis of enoxaparin versus unfractionated heparin in the secondary prevention of acute coronary syndrome. Pharmacoeconomics. 2002;20(14):979–87.

    Article  PubMed  CAS  Google Scholar 

  36. Detournay B, et al. Economic evaluation of enoxaparin sodium versus heparin in unstable angina. A French sub-study of the ESSENCE trial. Pharmacoeconomics. 2000;18(1):83–9.

    Article  PubMed  CAS  Google Scholar 

  37. Latour-Perez J, de-Miguel-Balsa E. Cost effectiveness of fondaparinux in non-ST-elevation acute coronary syndrome. Pharmacoeconomics. 2009;27(7):585–95.

    Article  PubMed  Google Scholar 

  38. Malhotra S, et al. A randomized trial to compare the efficacy, safety, cost and platelet aggregation effects of enoxaparin and unfractionated heparin (the ESCAPEU trial). Int J Clin Pharmacol Ther. 2001;39(3):110–5.

    Article  PubMed  CAS  Google Scholar 

  39. Mark DB, et al. Economic assessment of low-molecular-weight heparin (enoxaparin) versus unfractionated heparin in acute coronary syndrome patients: results from the ESSENCE randomized trial. Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q wave Coronary Events (unstable angina or non-Q-wave myocardial infarction). Circulation. 1998;97(17):1702–7.

    Article  PubMed  CAS  Google Scholar 

  40. Maxwell CB, et al. Cost-effectiveness analysis of anticoagulation strategies in non-ST-elevation acute coronary syndromes. Ann Pharmacother. 2009;43(4):586–95.

    Article  PubMed  Google Scholar 

  41. Nicholson T, McGuire A, Milne R. Cost-utility of enoxaparin compared with unfractionated heparin in unstable coronary artery disease. BMC Cardiovasc Disord. 2001;1:2.

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  42. O’Brien BJ, et al. Will the use of low-molecular-weight heparin (enoxaparin) in patients with acute coronary syndrome save costs in Canada? Am Heart J. 2000;139(3):423–9.

    Article  PubMed  Google Scholar 

  43. Orlewska E, Budaj A, Tereszkowski-Kaminski D. Cost-effectiveness analysis of enoxaparin versus unfractionated heparin in patients with acute coronary syndrome in Poland: modelling study from the hospital perspective. Pharmacoeconomics. 2003;21(10):737–48.

    Article  PubMed  CAS  Google Scholar 

  44. Pepe C, et al. Cost-effectiveness of fondaparinux in patients with acute coronary syndrome without ST-segment elevation. Arq Bras Cardiol. 2012;99(1):613–22.

    Article  PubMed  Google Scholar 

  45. Pinto DS, et al. Economic evaluation of bivalirudin with or without glycoprotein IIb/IIIa inhibition versus heparin with routine glycoprotein IIb/IIIa inhibition for early invasive management of acute coronary syndromes. J Am Coll Cardiol. 2008;52(22):1758–68.

    Article  PubMed  CAS  Google Scholar 

  46. Schwenkglenks M, et al. Cost-effectiveness of bivalirudin versus heparin plus glycoprotein IIb/IIIa inhibitor in the treatment of non-ST-segment elevation acute coronary syndromes. Value Health. 2011;14(1):24–33.

    Article  PubMed  Google Scholar 

  47. Sculpher MJ, et al. Fondaparinux versus enoxaparin in non-ST-elevation acute coronary syndromes: short-term cost and long-term cost-effectiveness using data from the fifth organization to assess strategies in acute ischemic syndromes investigators (OASIS-5) trial. Am Heart J. 2009;157(5):845–52.

    Article  PubMed  CAS  Google Scholar 

  48. Shafiq N, et al. A randomized controlled clinical trial to evaluate the efficacy, safety, cost-effectiveness and effect on PAI-1 levels of the three low-molecular-weight heparins–enoxaparin, nadroparin and dalteparin. The ESCAPe-END study. Pharmacology. 2006;78:136–43. doi:10.1159/000096484.

    Article  PubMed  CAS  Google Scholar 

  49. Mark DB, Hlatky MA. Medical economics and the assessment of value in cardiovascular medicine: part I. Circulation. 2002;106(4):516–20.

    Article  PubMed  Google Scholar 

  50. Yusuf S, et al. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med. 2001;345(7):494–502.

    Article  PubMed  CAS  Google Scholar 

  51. Mehta SR, et al. Effects of pretreatment with clopidogrel and aspirin followed by long-term therapy in patients undergoing percutaneous coronary intervention: the PCI-CURE study. Lancet. 2001;358(9281):527–33.

    Article  PubMed  CAS  Google Scholar 

  52. WHO. The Commission on Macroeconomic and Health. Macroeconomic and health: investing in health for economic development. Report of the Commission on Macroeconomics and Health. Geneva: WHO; 2001

  53. Wiviott SD, et al. Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2007;357(20):2001–15.

    Article  PubMed  CAS  Google Scholar 

  54. Husted S, van Giezen JJ. Ticagrelor: the first reversibly binding oral P2Y12 receptor antagonist. Cardiovasc Ther. 2009;27(4):259–74.

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  55. Price MJ. New antiplatelet therapies in development. Am J Health Syst Pharm. 2008;65(13 Suppl 5):S11–5 (quiz S16-8).

    Article  PubMed  CAS  Google Scholar 

  56. Wallentin L, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2009;361(11):1045–57.

    Article  PubMed  CAS  Google Scholar 

  57. Inhibition of platelet glycoprotein IIb/IIIa with eptifibatide in patients with acute coronary syndromes. The PURSUIT Trial Investigators. Platelet glycoprotein IIb/IIIa in unstable angina: receptor suppression using integrilin therapy. N Engl J Med 1998;339(7):436–43.

  58. Inhibition of the platelet glycoprotein IIb/IIIa receptor with tirofiban in unstable angina and non-Q-wave myocardial infarction. Platelet receptor inhibition in ischemic syndrome management in patients limited by unstable signs and symptoms (PRISM-PLUS) study investigators. N Engl J Med 1998;338(21):1488–97.

  59. Yusuf S, et al. Comparison of fondaparinux and enoxaparin in acute coronary syndromes. N Engl J Med. 2006;354(14):1464–76.

    Article  PubMed  CAS  Google Scholar 

  60. Bassand JP. The place of fondaparinux in the ESC and ACC/AHA guidelines for anticoagulation in patients with non-ST elevation acute coronary syndromes. Eur Heart J Suppl. 2008;10:C22–9.

    Article  CAS  Google Scholar 

  61. Drummond M, Sculpher M. Common methodological flaws in economic evaluations. Med Care. 2005;43(7 Suppl):5–14.

    PubMed  Google Scholar 

Download references

Acknowledgments

This review was commissioned by PharmacoEconomics and was not supported by any external funding. Fotini Gialama, Evangelia Miloni and Nikos Maniadakis have no conflicts of interest that are directly relevant to the content of this manuscript. Fotini Gialama contributed to the conception and design of the study; literature research; data extraction; data analysis and interpretation; quality assessment of studies and manuscript preparation. Evangelia Miloni contributed to the literature search; quality assessment of studies and manuscript preparation. Nikos Maniadakis contributed to the conception and design of the study; supervised and reviewed the manuscript; approved the final version of the manuscript; and is guarantor of the overall content of this review.

Author information

Authors and Affiliations

  1. Department of Health Services Organization and Management, National School of Public Health, 196 Alexandras Avenue, 115 21, Athens, Greece

    Fotini Gialama, Evangelia Miloni & Nikos Maniadakis

Authors
  1. Fotini Gialama
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Evangelia Miloni
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Nikos Maniadakis
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Nikos Maniadakis.

Electronic supplementary material

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Gialama, F., Miloni, E. & Maniadakis, N. Cost Effectiveness of Treatments for non-ST-segment elevation Acute Coronary Syndrome. PharmacoEconomics 32, 1063–1078 (2014). https://doi.org/10.1007/s40273-014-0191-5

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40273-014-0191-5

Keywords

Search

Navigation