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MI - Cost effectiveness of tPA vs streptokinase in acute MI

Clinical Bottom Line
The cost effectiveness of treatment with tPA rather than SK compares favorably with that of many generally accepted medical services. The use of tPA is most cost effective in older patients ( >75 yrs).

Appraised by S Straus, March 5, 1997

Expiry Date: March 1998

Search Terms
myocardial infarction, thrombolysis in Best Evidence

The Study
* 41021 pts in the GUSTO study provided data for survival
* data on the use of medical resources during the initial hospitalization were provided by the 23105 US patients
* data on the use of medical resources and quality of life for the 12-month follow-up were provided by a random sample of 2600 US pts
* pts were assigned to tPA, SK with IV heparin, SK with SQ heparin or tPA and SK

The Evidence
Group of Pts Cost-effectiveness Ratio (in $) per yr of life saved
Primary analysis 32678
Inferior MI, <40 203071
Anterior MI, <40 123609
Inferior MI, 41-60 74816
Anterior MI, 41-60 49877
Inferior MI, 61-75 27873
Anterior MI, 61-75 20601
Inferior MI, >75 16246
Anterior MI, >75 13410

Comments

  1. in the sensitivity analysis, the threshold ratio of $50000 per yr of life saved was not exceeded until the increased survival for the tPA group fell below 7 yrs of life added per 100 pts treated (14 yrs of life added per 100 pts treated with tPA from trial)
  2. results not sensitive to changes in estimates of costs
  3. even the most unfavourable assumptions about nonfatal disabling stroke - that pts with stroke had no increase in survival due to tPA and that each pt would require 15 yrs of institutional care - increased the cost-effectiveness ratio only moderately
  4. in comparison, CABG vs medical therapy for left main disease results in $7000 per yr of life saved, medical therapy compared with no therapy for severe hypertension in $20000 per yr of life saved, hemodialysis as compared to no dialysis $35000 per yr of life saved.

Reference:

  1. Mark DB, Hlatky MA, Califf RM et al. Cost effectiveness of thrombolytic therapy with tPA as compared with streptokinase for acute myocardial infraction. N Engl J Med 1995;332:1418-24.

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