Heart Failure Reviews

, Volume 24, Issue 6, pp 967–975 | Cite as

Cost-effectiveness of coronary artery bypass graft and percutaneous coronary intervention compared to medical therapy in patients with coronary artery disease: a systematic review

  • Saeed Sheikh Gholami
  • Farbod Ebadi Fard AzarEmail author
  • Aziz Rezapour
  • Masih Tajdini


Coronary artery disease (CAD) has significant social and economic implications. It is necessary to create tools to identify the most cost-effectiveness treatments, which can assist clinicians in their therapeutic decisions so that the maximum possible benefit is reached with the lowest possible cost. Effectiveness must be measured by final treatment goals in which the most effective interventions are those with the lowest costs. This study is aimed to systematically review and compare the studies conducted on the cost-effectiveness of the three coronary artery disease treatment strategies (medical treatment, percutaneous coronary intervention, and coronary artery bypass graft). In this systematic review, the databases NHS Economic Evaluation Database, Embase, MEDLINE, Science Direct, and Scopus were searched for studies on the cost-effectiveness of coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) compared to medical therapy (MT) in patients with coronary artery disease between 1 January 2004 to 30 September 2018. The quality appraisal of the included studies was examined using the Consolidated Health Economics Evaluation Reporting Standards (CHEERS) statement. Out of 186 unique retrievals, 8 studies were included. The results showed that the all studies clearly stated the time horizon of the study and included direct medical costs in their analysis. In addition, in most of the studies, quality-adjusted life years (QALY) were the main outcome used for measuring the effectiveness. The studies reported various ranges of the incremental cost-effectiveness ratio (ICER); accordingly, the highest ratio was observed in the USA ($212,800) for PCI v MT and the lowest ratio was observed in Brazil ($4403) for CABG v MT. Although the results of the studies were different in terms of a number of aspects, such as the viewpoint of the study, the study horizons, and the costs of expenditure items, they reached similar results. Based on the result of the present study, it seems that each three treatment strategies for CAD yielded improvements in QALY.


Cost-effectiveness Coronary artery disease Coronary artery bypass graft Percutaneous coronary intervention Medical therapy Economic evaluation 



This study was part of a PhD thesis supported by the Iran University of Medical Sciences (Grant No. IUMS/SHMIS-97-02-136-33863).

Compliance with ethical standards

The manuscript does not contain clinical studies or patient data.

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Allender S, Scarborough P, Peto V, Rayner M (2014).European cardiovascular disease statistics 2012 European heart network: Brussels.Google Scholar
  2. 2.
    Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Blaha MJ et al (2013) Heart disease and stroke statistics—2014 update: a report from the American Heart Association. Circulation 129(3):232Google Scholar
  3. 3.
    Hlatky MA, Boothroyd DB, Bravata DM, Boersma E, Booth J, Brooks MM, Carrié D, Clayton TC, Danchin N, Flather M, Hamm CW, Hueb WA, Kähler J, Kelsey SF, King SB, Kosinski AS, Lopes N, McDonald KM, Rodriguez A, Serruys P, Sigwart U, Stables RH, Owens DK, Pocock SJ (2009) Coronary artery bypass surgery compared with percutaneous coronary interventions for multivessel disease: a collaborative analysis of individual patient data from ten randomised trials. Lancet 373(9670):1190–1197CrossRefGoogle Scholar
  4. 4.
    Hueb W, Lopes NH, Gersh BJ, Soares P, Machado LA, Jatene FB (2007) A randomized controlled clinical trial of 3 therapeutic strategies for multivessel coronary artery disease. Circulation 115(9):1082–1089CrossRefGoogle Scholar
  5. 5.
    Sculpher MJ, Buxton MJ, Seed P, Pocock SJ, Henderson RA, Parker J, Joy MD, Sowton E, Hampton JR, for RITA trial participants (1994) Health service costs of coronary angioplasty and coronary artery bypass surgery: the Randomised Intervention Treatment of Angina (RITA) trial. Lancet 344(8927):927–930CrossRefGoogle Scholar
  6. 6.
    Serruys PW, Unger F, Sousa JE, Jatene A, Bonnier HJRM, Schönberger JPAM, Buller N, Bonser R, van den Brand M, van Herwerden L, Morel MA, van Hout B, Arterial Revascularization Therapies Study Group (2001) Comparison of coronary-artery bypass surgery and stenting for the treatment of multivessel disease. N Engl J Med 344(15):1117–1124CrossRefGoogle Scholar
  7. 7.
    Rezapour A, Faradonbeh SB, Alipour V, Yusefvand M (2018) Effectiveness of revascularization interventions compared with medical therapy in patients with ischemic cardiomyopathy: a systematic review protocol. Medicine. 97(10):e9958CrossRefGoogle Scholar
  8. 8.
    Chaitman BR, Ryan TJ, Kronmal RA, Foster ED, Frommer PL, Killip T (1990) Coronary artery surgery study (CASS): comparability of 10 year survival in randomized and randomizable patients. J Am Coll Cardiol 16(5):1071–1078CrossRefGoogle Scholar
  9. 9.
    Weintraub WS, Becker ER, Mauldin PD, Culler S, Kosinski AS, King Iii SB (2000) Costs of revascularization over eight years in the randomized and eligible patients in the Emory Angioplasty Versus Surgery Trial (EAST). Am J Cardiol 86(7):747–752CrossRefGoogle Scholar
  10. 10.
    Weintraub WS, Boden WE, Zhang Z, Kolm P, Zhang Z, Spertus JA, Hartigan P, Veledar E, Jurkovitz C, Bowen J, Maron DJ, O'Rourke R, Dada M, Teo KK, Goeree R, Barnett PG, Department of Veterans Affairs Cooperative Studies Program No. 424 (COURAGE Trial) Investigators and Study Coordinators (2008) Cost-effectiveness of percutaneous coronary intervention in optimally treated stable coronary patients clinical perspective. Circulation: Cardiovascular Quality and Outcomes 1(1):12–20Google Scholar
  11. 11.
    Vieira RDO, Hueb W, Hlatky M, Favarato D, Rezende PC, Garzillo CL et al (2012) Cost-effectiveness analysis for surgical, angioplasty, or medical therapeutics for coronary artery disease: 5-year follow-up of medicine, angioplasty, or surgery study (MASS) II trial. Circulation 126(11_suppl_1):S145–SS50CrossRefGoogle Scholar
  12. 12.
    Drummond MF, Sculpher MJ, Claxton K, Stoddart GL, Torrance GW (2015) Methods for the economic evaluation of health care programmes. 4ed. Oxford University Press: Oxford.Google Scholar
  13. 13.
    Almasiankia A, Kavosi Z, Keshtkaran A, Jafari A, Goodarzi S (2015) Equity in health care financing among Iranian households. Shiraz: SEMJ. 16(11–12):6Google Scholar
  14. 14.
    Ravangard R, Hatam N, Teimourizad A, Jafari A (2014) Factors affecting the technical efficiency of health systems: a case study of Economic Cooperation Organization (ECO) countries (2004–10). Int J Health Policy Manag 3(2):63–69CrossRefGoogle Scholar
  15. 15.
    Jafari A, Rezapour A, Hajahmadi M (2018) Cost-effectiveness of B-type natriuretic peptide-guided care in patients with heart failure: a systematic review. Heart Fail Rev 23(5):1–8CrossRefGoogle Scholar
  16. 16.
    Husereau D, Drummond M, Petrou S, Carswell C, Moher D, Greenberg D, Augustovski F, Briggs AH, Mauskopf J, Loder E, on behalf of the CHEERS Task Force (2013) Consolidated health economic evaluation reporting standards (CHEERS) statement. Cost Effectiveness and Resource Allocation 11(1):6CrossRefGoogle Scholar
  17. 17.
    Hlatky MA, Boothroyd DB, Melsop KA, Kennedy L, Rihal C, Rogers WJ, Venkitachalam L, Brooks MM, Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) Study Group (2009) Economic outcomes of treatment strategies for type 2 diabetes mellitus and coronary artery disease in the Bypass Angioplasty Revascularization Investigation 2 Diabetes trial. Circulation 120(25):2550–2558CrossRefGoogle Scholar
  18. 18.
    Griffin S, Barber J, Manca A, Sculpher M, Thompson S, Buxton M et al (2007) Cost effectiveness of clinically appropriate decisions on alternative treatments for angina pectoris: prospective observational study. BMJ 334(7594):624CrossRefGoogle Scholar
  19. 19.
    Fidan D, Unal B, Critchley J, Capewell S (2007) Economic analysis of treatments reducing coronary heart disease mortality in England and Wales, 2000–2010. J Assoc Physicians 100(5):277–289Google Scholar
  20. 20.
    Brandão SMG, Rezende PC, Brunner-La Rocca H-P, Ju YT, de Lima ACP, Takiuti ME et al (2018) Comparative cost-effectiveness of surgery, angioplasty, or medical therapy in patients with multivessel coronary artery disease: MASS II trial. CERA 16(1):55PubMedGoogle Scholar
  21. 21.
    Caruba T, Katsahian S, Schramm C, Nelson AC, Durieux P, Bégué D et al (2014) Treatment for stable coronary artery disease: a network meta-analysis of cost-effectiveness studies. PLoS One 9(6):e98371CrossRefGoogle Scholar
  22. 22.
    Augustovski F, Iglesias C, Manca A, Drummond M, Rubinstein A, Martií SG (2009) Barriers to generalizability of health economic evaluations in Latin America and the Caribbean region. Pharmacol Econ 27(11):919–929CrossRefGoogle Scholar
  23. 23.
    Baltussen RMPM, Hutubessy RCW, Evans DB, Murray CJM (2002) Uncertainty in cost-effectiveness analysis: probabilistic uncertainty analysis and stochastic league tables. Int J Technol Assess Healthc 18(1):112–119Google Scholar
  24. 24.
    Ghabri S, Hamers FF, Josselin J-M, Harousseau J-L (2014) Exploring uncertainty in economic evaluation of medicines: a review of the first manufacturers’ submissions to the French National Authority for Health (HAS). Value Health 17(7):A441–A4A2CrossRefGoogle Scholar
  25. 25.
    Limwattananon S (2014) Sensitivity analysis for handling uncertainty in an economic evaluation. J Med Assoc Thail 97:S59–S64Google Scholar
  26. 26.
    Hatam N, Dehghani M, Habibian M, Jafari A (2015) Cost-utility analysis of IEV drug regimen versus ESHAP drug regimen for the patients with relapsed and refractoryh Hodgkin and non-Hodgkin’s lymphoma in Iran. Iran J Cancer Prev 8(5):e4061CrossRefGoogle Scholar
  27. 27.
    Claude J, Schindler C, Kuster GM, Schwenkglenks M, Szucs T, Buser P et al (2004) Cost-effectiveness of invasive versus medical management of elderly patients with chronic symptomatic coronary artery disease: findings of the randomized trial of invasive versus medical therapy in elderly patients with chronic angina (TIME). Eur Heart J 25(24):2195–2203CrossRefGoogle Scholar
  28. 28.
    Boden WE, O'Rourke RA, Teo KK, Hartigan PM, Maron DJ, Kostuk WJ, Knudtson M, Dada M, Casperson P, Harris CL, Chaitman BR, Shaw L, Gosselin G, Nawaz S, Title LM, Gau G, Blaustein AS, Booth DC, Bates ER, Spertus JA, Berman DS, Mancini GB, Weintraub WS, COURAGE Trial Research Group (2007) Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med 356(15):1503–1516CrossRefGoogle Scholar
  29. 29.
    Gaziano TA, Bitton A, Anand S, Abrahams-Gessel S, Murphy A (2010) Growing epidemic of coronary heart disease in low-and middle-income countries. Curr Probl Cardiol 35(2):72–115CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Health Economics, School of Health Management and Information SciencesIran University of Medical SciencesTehranIran
  2. 2.Health Management and Economics Research CenterIran University of Medical SciencesTehranIran
  3. 3.Tehran Heart CenterTehran University of Medical SciencesTehranIran

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