Cost-Effectiveness of Percutaneous Coronary Intervention with Drug-Eluting Stents vs. Bypass Surgery for Patients with 3-Vessel or Left Main Coronary Artery Disease: Final Results from the SYNTAX Trial
Background—The SYNTAX trial demonstrated that in patients with 3-vessel or left-main CAD, CABG was associated with a lower rate of cardiovascular death, MI, stroke, or repeat revascularization compared with DES-PCI. The long-term cost-effectiveness of these strategies is unknown.
Methods and Results—Between 2005 and 2007, 1800 patients with left-main or 3-vessel CAD were randomized to CABG (n=897) or DES-PCI (n=903). Costs were assessed from a US perspective, and health state utilities were evaluated with the EuroQOL questionnaire. A patient-level micro-simulation model based on the 5-year in-trial data was used to extrapolate costs, life expectancy, and quality-adjusted life expectancy over a lifetime horizon. Although initial procedural costs were $3415/patient lower with CABG, total hospitalization costs were $10,036/patient higher. Over the next 5 years, follow-up costs were higher with DES-PCI, owing to more frequent hospitalizations, revascularization procedures, and higher medication costs. Over a lifetime horizon, CABG remained more costly than DES-PCI but the incremental cost-effectiveness ratio was favorable ($16,537/ QALY gained) and remained <$20,000/QALY in most bootstrap replicates. Results were consistent across a wide range of assumptions regarding the long-term effect of CABG vs. DES-PCI on events and costs. In patients with left-main disease or a SYNTAX Score ≤22, however, DES-PCI was economically dominant compared with CABG although these findings were less certain.
Conclusions—For most patients with 3-vessel or left-main CAD, CABG is a clinically and economically attractive revascularization strategy compared with DES-PCI. However, among patients with less complex disease, DES-PCI may be preferred on both clinical and economic grounds.
Clinical Trial Registration Information—www.clinicaltrials.gov. Identifier: NCT00114972.
- bypass surgery
- percutaneous coronary intervention
- drug-eluting stent
- cost-benefit analysis
- randomized controlled trial
- Received March 11, 2014.
- Revision received July 8, 2014.
- Accepted July 24, 2014.