COST-EFFECTIVENESS OF THERAPIES FOR PATIENTS WITH NONVALVULAR ATRIAL-FIBRILLATION

Background: The most appropriate treatment(s) for patients with atrial fibrillation remains uncertain. Objective: To examine the cost-effect iveness of antithrombotic and antiarrhythmic treatment strategies for atrial fibrillation. Methods: We performed decision and cost-effective ness analyses using a Markov state transition model. We gathered data from the English-language literature using MEDLINE searches and biblio graphies from selected articles. We obtained financial data from natio n wide physician-fee references, a medical center's cost accounting sy stem, and one of New England's larger managed care organizations. We e xamined strategies that included combinations of cardioversion, antiar rhythmic therapy with quinidine, sotalol hydrochloride, or amiodarone, and anticoagulant or antiplatelet therapy. Results: For a 65-year-old man with nonvalvular atrial fibrillation, any intervention results in a significant gain in quality-adjusted life years (QALYs) compared wi th no specific therapy. Use of aspirin results in the largest incremen tal gain (1.2 QALYs). Cardioversion followed by the use of amiodarone and warfarin together is the most effective strategy, Yielding a gain of 2.3 QALYs compared with no specific therapy. The marginal cost-effe ctiveness ratios of cardioversion followed by aspirin, with or without amiodarone, are $33 800 per QALY and $10 800 per QALY, respectively. Cardioversion followed by amiodarone and warfarin has a marginal cost- effectiveness ratio of $92 400 per QALY compared with amiodarone and a spirin. Strategies that include cardioversion followed by either quini dine or sotalol are both more expensive and less effective than compet ing strategies. Conclusions: Cardioversion of patients with nonvalvula r atrial fibrillation followed by the use of aspirin alone or with ami odarone has a reasonable marginal cost-effectiveness ratio. While card ioversion followed by the use of amiodarone and warfarin results in th e greatest gain in quality-adjusted life expectancy, it is expensive ( ie, has a high marginal cost-effectiveness ratio) compared with aspiri n and amiodarone. Finally, for patients who are bothered little by sym ptoms of atrial fibrillation, cardioversion followed by either aspirin or warfarin without subsequent antiarrhythmic therapy is the treatmen t of choice.