ANALYSIS OF THE RELATIVE COSTS AND EFFECTIVENESS OF PRIMARY ANGIOPLASTY VERSUS TISSUE-TYPE PLASMINOGEN-ACTIVATOR - THE PRIMARY ANGIOPLASTY IN MYOCARDIAL-INFARCTION (PAMI) TRIAL

Objectives. We sought to determine the relative cost and effectiveness of two different reperfusion modalities in patients with acute myocar dial infarction (AMI). Background. Recent studies have found superior clinical outcomes after reperfusion by primary percutaneous translumin al coronary angioplasty (PTCA) compared with thrombolytic therapy. The high up-front costs of cardiac catheterization may diminish the relat ive advantages of this invasive strategy. Methods. Detailed in-hospita l charge data were available from all 358 patients with AMI randomized to tissue-type plasminogen activator (t-PA) or primary PICA in the Un ited States from the Primary Angioplasty in Myocardial Infarction tria l. Resource consumption during late follow-up was estimated by assessm ent of major clinical events and functional status. Results. Compared with t-PA, primary PICA resulted in reduced rates of in-hospital morta lity (2.3% vs. 7.2%, p = 0.03), reinfarction (2.8% vs. 7.2%, p = 0.06) , recurrent ischemia (11.3% vs. 28.7%, p < 0.0001) and stroke (0% vs. 3.9%, p = 0.02) and a shorter hospital stay (7.6 +/- 33 days vs. 8.4 /- 4.7 days, p = 0.04). Despite the initial costs of cardiac catheteri zation in all patients with the invasive strategy, total mean (+/-SD) hospital charges were $3,436 lower per patient with PICA than with t-P A ($23,468 +/- $13,410 vs. $26,904 + $18,246, p = 0.04), primarily due to the reduction in adverse in-hospital outcomes. However, profession al fees were higher after primary PICA ($4,185 +/- $3,183 vs. $3,322 /- $2,728, p = 0.001), and thus total charges, although favoring PICA, were not significantly different ($27,653 +/- $13,709 vs. $30,227 + 1 8,903, p = 0.21). At a mean follow-up time of 2.1 +/- 0.7 years, no ma jor differences in postdischarge events or New York Heart Association functional class were present between PICA- and t-PA-treated patients, suggesting similar late resource consumption. Including in-hospital e vents, 83% of PTCA-treated patients were alive and free of reinfarctio n at late follow-up, compared with 74% of t-PA-treated patients (p = 0 .06). Conclusions. Compared with t-PA, reperfusion by primary PICA imp roves clinical outcomes with similar or reduced costs. These findings have important clinical implications in an increasingly cost-conscious health care environment.