Published Online
on November 10, 2003

A more recent version of this article appeared on December 9, 2003

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Submitted on August 8, 2003
Revised on September 23, 2003
Accepted on September 25, 2003

Cost-Effectiveness of Coronary Stenting and Abciximab for Patients With Acute Myocardial Infarction. Results From the CADILLAC (Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications) Trial

Ameet Bakhai MD, MRCP, Gregg W. Stone MD, Cindy L. Grines MD, Sabina A. Murphy MPH, Louise Githiora BA, Ronna H. Berezin MPH, David A. Cox MD, Thomas Stuckey MD, John J. Griffin MD, James E. Tcheng MD, David J. Cohen MD, MSc^*, and for the CADILLAC Investigators

From the Harvard Clinical Research Institute (A.B., S.A.M., L.G., R.H.B., D.J.C.), the Division of Cardiology, Beth Israel-Deaconess Medical Center, Boston, Mass (A.B., D.J.C.); the Clinical Trials and Evaluation Unit, Royal Brompton Hospital, London, UK (A.B.); Lenox Hill Hospital, New York, NY (G.W.S.); William Beaumont Hospital, Royal Oak, Mich (C.L.G.); Mid-Carolina Cardiology, Charlotte, NC (D.A.C.); Moses Cone Memorial Hospital, Greensboro, NC (T.S.); Virginia Beach General Hospital, Virginia Beach, Va (J.J.G.); and Duke University, Durham, NC (J.E.T.).

^* To whom correspondence should be addressed. E-mail: dcohen{at}caregroup.harvard.edu.

Background--Both stenting and the glycoprotein IIb/IIIa inhibitor abciximab improve outcomes for patients undergoing primary angioplasty for acute myocardial infarction (AMI). However, the cost-effectiveness of these strategies is unknown.

Methods and Results--We performed a prospective cost-utility analysis among US participants in the CADILLAC trial. Patients with AMI (n=1703) were randomized to stenting versus balloon angioplasty (PTCA) and abciximab versus no abciximab according to a 2-by-2 factorial design. Total 1-year costs and lifetime incremental cost-effectiveness ratios, measured as cost per quality-adjusted year of life (QALY) gained, were calculated. Compared with PTCA, stenting increased procedural costs by $1148 and initial hospital costs by $1384 (both P<0.001). By 1-year, stenting led to fewer repeat revascularization procedures and reduced follow-up medical care costs by $1215, such that aggregate costs were similar for the PTCA and stent groups ($18 690 versus $18 859, P=0.75). The cost-effectiveness ratio for stenting versus PTCA was favorable at $11 237/QALY gained and remained <$20 000/QALY in sensitivity analyses. Compared with standard anticoagulation, abciximab increased initial procedural costs by $1122 (P<0.001). By facilitating accelerated hospital discharge, abciximab reduced length of stay by 0.6 days, offsetting most of the drug costs. These cost offsets were not maintained, however; aggregate 1-year costs for the abciximab group were $1244 greater than for standard therapy ($19 389 versus $18 145, P=0.02). Abciximab was reasonably cost-effective (cost-effectiveness ratio $21 305/QALY) only if nonsignificant differences in 1-year mortality (3.7% versus 4.3%, P=0.62) were incorporated in the analysis.

Conclusions--Primary stenting is a highly cost-effective treatment for AMI. The cost-effectiveness of abciximab in this setting is uncertain and depends primarily on whether long-term survival is enhanced.

Key words: angioplasty • myocardial infarction • stents • cost-benefit analysis

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