, Volume 26, Issue 10, pp 861–877

Costs and Effects of Secondary Prevention with Perindopril in Stable Coronary Heart Disease in Poland

An Analysis of the EUROPA Study Including 1251 Polish Patients
  • W. Ken Redekop
  • Ewa Orlewska
  • Pawel Maciejewski
  • Frans F. H. Rutten
  • Louis W. Niessen
Original Research Article


Objectives: To estimate the long-term impact of treatment with perindopril on costs and health effects in patients with stable coronary artery disease in Poland.

Methods: The cost-effectiveness analysis was based on data from a randomized double-blind, placebo-controlled trial. A decision-tree analysis was employed, including Monte Carlo and bootstrapping techniques. This study was a sub-study of the EUROPA (European Trial on Reduction of Cardiac Events with Perindopril in Stable Coronary Artery Disease) trial (n = 12 218; mean follow-up 4.2 years). Resource use was based on data from Polish EUROPA study patients (n = 1251), while effectiveness was based on the whole EUROPA study. The health gain of perindopril in life-years was based on overall EUROPA study results, and the adapted Polish life expectancy of patients not dying during the trial. Costs were calculated in new Polish zloty (PLN), year 2003 values; €1 = PLN4.053. Only direct healthcare costs related to cardiovascular events and medication use were studied.

Results: When observed mortality was combined with life expectancy beyond the end of the study, perindopril use showed a gain in life expectancy of 0.182 lifeyears (SD ± 0.129) at a cost of PLN1983 (SD ± 103) with discounting of 5% per annum on costs and no discounting on effects. This resulted in an incremental cost-effectiveness ratio (ICER) of PLN10 896 per life-year gained. The probability that the ICER for perindopril was below the threshold of PLN60 000 was 88%. The overall results were insensitive to discount rates for costs and life-years.

Conclusions: Perindopril leads to a reduction in the risk of coronary events among patients with stable heart disease. When the expected improvement in life expectancy is combined with associated medical costs, there is a high probability that perindopril is cost effective, given the threshold of PLN60 000 per life-year gained.


  1. 1.
    Rutherford JD, Pfeffer MA, Moye LA, et al. Effects of captopril on ischemic events after myocardial infarction: results of the Survival and Ventricular Enlargement trial. SAVE Investigators. Circulation 1994 Oct; 90 (4): 1731–8PubMedCrossRefGoogle Scholar
  2. 2.
    Yusuf S, Pepine CJ, Garces C, et al. Effect of enalapril on myocardial infarction and unstable angina in patients with low ejection fractions. Lancet 1992 Nov 14; 340 (8829): 1173–8PubMedCrossRefGoogle Scholar
  3. 3.
    Yusuf S, Sleight P, Pogue J, et al. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators. N Engl J Med 2000 Feb 20; 342 (3): 145–53PubMedCrossRefGoogle Scholar
  4. 4.
    Fox KM. Efficacy of perindopril in reduction of cardiovascular events among patients with stable coronary artery disease: randomised, double-blind, placebo-controlled, multicentre trial (the EUROPA study). Lancet 2003 Sep 6; 362 (9386): 782–8PubMedCrossRefGoogle Scholar
  5. 5.
    Efron B, Tibshirani R. An introduction to the bootstrap. New York: Chapman and Hill, 1993Google Scholar
  6. 6.
    Cook JR, Drummond M, Glick H, et al. Assessing the appropriateness of combining economic data from multinational clinical trials. Stat Med 2003 Jun 30; 22 (12): 1955–76PubMedCrossRefGoogle Scholar
  7. 7.
    Reed SD, Anstrom KJ, Bakhai A, et al. Conducting economic evaluations alongside multinational clinical trials: toward a research consensus. Am Heart J 2005 Mar; 149 (3): 434–43PubMedCrossRefGoogle Scholar
  8. 8.
    van Hout BA, Al MJ, Gordon GS, et al. Costs, effects and C/E-ratios alongside a clinical trial. Health Econ 1994 Sep-Oct; 3 (5): 309–19PubMedCrossRefGoogle Scholar
  9. 9.
    Briggs A, Fenn P. Confidence intervals or surfaces? Uncertainty on the cost-effectiveness plane. Health Econ 1998 Dec; 7 (8): 723–40PubMedCrossRefGoogle Scholar
  10. 10.
    ESC/ACC Committee. Myocardial infarction redefined: a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction. Eur Heart J 2000 Sep; 21 (18): 1502–13CrossRefGoogle Scholar
  11. 11.
    Orlewska E, Cel M. Standard list of inpatient costs [in Polish]. Farmakoekonomika 2003; 6 (2): 1–22Google Scholar
  12. 12.
    National Health Fund Management Resolution 164/2004 of 01/07/2004 on setting the catalog of inpatient medical services (appendix 1) [in Polish]. Warsaw: National Health Fund (Poland), 2004Google Scholar
  13. 13.
    Eurostat. Harmonized Indices of Consumer Prices (HICPs). All items: index[online]. Available from URL:,39140985&_dad= portal&_schema=PORTAL&screen=detailref&language=en &product=EU_shorties&root=EU_shorties/shorties/euro_cp/cp000 [Accessed 2008 Jun 5]Google Scholar
  14. 14.
    Data on file, IMS Poland National Data 2004 (IMS data view).Google Scholar
  15. 15.
    Prosper pharmaceutical wholesale pricelist 2004 [in Polish]. Warsaw: Prosper, 2004Google Scholar
  16. 16.
    Polish register of reimbursed pharmaceuticals II 2004 [in Polish]. Piotrków Trybunalski: Wydawnictwo JWC, 2004Google Scholar
  17. 17.
    Orlewska E, Mierzejewski P. Project of Polish guidelines for conducting pharmacoeconomic evaluations in comparison to international health economic guidelines. Eur J Health Econ 2003 Nov; 4 (4): 296–303PubMedCrossRefGoogle Scholar
  18. 18.
    Orlewska E, Mierzejewski P. Project of Polish guidelines for costing: methods and standard costs for pharmacoeconomic evaluations [in Polish]. Farmacoeconomika 2003; 1: 2–8Google Scholar
  19. 19.
    Brouwer WB, Niessen LW, Postma MJ, et al. Need for differential discounting of costs and health effects in cost effectiveness analyses. BMJ 2005 Aug 20; 331 (7514): 446–8PubMedCrossRefGoogle Scholar
  20. 20.
    Gold M, Siegel J, Russell L, et al., editors. Cost-effectiveness in health and medicine. 1st ed. New York: Oxford University Press, 1996Google Scholar
  21. 21.
    Briggs AH. Handling uncertainty in cost-effectiveness models. Pharmacoeconomics 2000 May; 17 (5): 479–500PubMedCrossRefGoogle Scholar
  22. 22.
    National Institute for Health and Clinical Excellence. Guide to the methods of technology appraisal. London: National Institute for Health and Clinical Excellence, 2004 AprGoogle Scholar
  23. 23.
    Orlewska E. The cost-effectiveness of Arthrotec 75 versus diclofenac SR 75 in the treatment of rheumatoid arthritis and osteoarthritis in Poland [in Polish]. Farmakoekonomika 2000; 1: 2–18Google Scholar
  24. 24.
    World health report 2002. Geneva: World Health Organization, 2002Google Scholar
  25. 25.
    Macroeconomics and health: investing in health for economic development: report of the Commission on Macroeconomics and Health. Geneva: World Health Organization, 2001Google Scholar
  26. 26.
    The world health report 2002: Reducing risks, promoting healthy life. Geneva, World Health Organization[online]. Available from URL: [Accessed 2008 Jun 23]
  27. 27.
    Briggs A, Mihaylova B, Sculpher M, et al. The cost-effectiveness of perindopril in reducing cardiovascular events in patients with stable coronary artery disease using data from the EUROPA Study. Heart 2007 Sep; 93 (9): 1081–6PubMedCrossRefGoogle Scholar
  28. 28.
    Drummond MF, O’Brien B, Stoddart GL, et al. Methods for the economic evaluation of health care programmes. 2nd ed. Oxford: Oxford University Press, 1997Google Scholar
  29. 29.
    Lamy A, Yusuf S, Pogue J, et al. Cost implications of the use of ramipril in high-risk patients based on the Heart Outcomes Prevention Evaluation (HOPE) study. Circulation 2003 Feb 25; 107 (7): 960–5PubMedCrossRefGoogle Scholar

Copyright information

© Adis Data Information BV 2008

Authors and Affiliations

  • W. Ken Redekop
    • 1
  • Ewa Orlewska
    • 2
  • Pawel Maciejewski
    • 3
  • Frans F. H. Rutten
    • 2
  • Louis W. Niessen
    • 1
    • 4
  1. 1.Institute for Medical Technology Assessment and Institute of Health Policy and Management, Erasmus MCUniversity Medical Center RotterdamRotterdamthe Netherlands
  2. 2.Centre for PharmacoeconomicsWarsawPoland
  3. 3.Department of Cardiology, Postgraduate Medical School WarsawGrochowski HospitalWarsawPoland
  4. 4.Department of International Health, Johns Hopkins Bloomberg School of Public HealthJohns Hopkins UniversityBaltimoreUSA

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