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Summaries for Patients are a service provided by Annals to help patients better understand the complicated and often mystifying language of modern medicine.
SUMMARIES FOR PATIENTS
Cost-Effectiveness of Implantable Defibrillators versus the Drug Amiodarone To Prevent Abnormal Heart Rhythms after Heart Attack
20 November 2001 | Volume 135 Issue 10 | Page S56
Summaries for Patients are presented for informational purposes only. These summaries are not a substitute for advice from your own medical provider. If you have questions about this material, or need medical advice about your own health or situation, please contact your physician. The summaries may be reproduced for not-for-profit educational purposes only. Any other uses must be approved by the American College of Physicians-American Society of Internal Medicine.
The summary below is from the full report titled "Potential Cost-Effectiveness of Prophylactic Use of the Implantable Cardioverter Defibrillator or Amiodarone after Myocardial Infarction." It is in the 20 November 2001 issue of Annals of Internal Medicine (volume 135, pages 870–883). The authors are GD Sanders, MA Hlatky, NR Every, KM McDonald, PA Heidenreich, LS Parsons, and DK Owens.
What is the problem and what is known about it so far?
After a heart attack, some patients develop a dangerous heart rhythm called sustained ventricular arrhythmia. If the patient is in the hospital, doctors or nurses apply an electric shock to the chest to stop the rhythm (external cardioversion). It is now possible to place a device called an implantable cardioverter defibrillator (ICD), which monitors heart rhythm, inside the chest. When it detects a dangerous rhythm, it applies an electrical shock to restore a normal heart rhythm. The ICD improves the survival of people who have had sustained ventricular arrhythmias. These dangerous rhythms could also be prevented by treatment with a drug, such as amiodarone. However, the balance between the costs of these treatments and their potential benefits is not known.
Why did the researchers do this particular study?
To find out how effective the ICD or amiodarone would need to be in patients who have had heart attacks to make it an efficient way to use taxpayer dollars.
Who was studied?
The researchers developed a computer model to simulate a hypothetical group of patients who had had heart attacks but had not yet had a sustained ventricular arrhythmia.
How was the study done?
The computer model simulated the outcomes and costs that would apply if patients with heart attack received an ICD, amiodarone, or no special therapy. To estimate what might happen to patients and how much each option might cost, the authors used information from previous studies, a patient registry, and expert opinion. The researchers defined therapy costing less than $75,000 for every extra year of healthy life gained by the treatment as reasonably efficient (cost-effective). The model calculated how many deaths ICDs or amiodarone would need to prevent to cost less than $75,000 per extra year of healthy life saved.
What did the researchers find?
Compared with no treatment, ICDs had the fewest deaths and the highest costs, while amiodarone had intermediate benefits and costs. To cost less than $75,000 per quality-adjusted life-year, ICDs would need to reduce the number of deaths from ventricular arrhythmias by half in patients with heart failure. Because amiodarone is much less expensive than ICDs, it would need to reduce total deaths by only 7% to be cost-effective at this level.
What were the limitations of the study?
It is not yet known how effective ICDs and amiodarone are in preventing deaths in patients who have had heart attacks but have not yet experienced an arrhythmia. This study estimates only how effective these preventive treatments would need to be in order to be reasonably cost-effective.
What are the implications of the study?
If future studies show that ICDs can reduce the number of arrhythmic deaths by half in patients with heart failure or that amiodarone can reduce total deaths by 7%, these preventive strategies may offer benefit at levels of cost-effectiveness that society typically considers reasonable.
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This article has been cited by other articles:
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J. P. DiMarco Implantable Cardioverter-Defibrillators N. Engl. J. Med., November 6, 2003; 349(19): 1836 - 1847. [Full Text] [PDF]
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M. R. Reynolds and M. E. Josephson MADIT II (Second Multicenter Automated Defibrillator Implantation Trial) Debate: Risk Stratification, Costs, and Public Policy Circulation, October 14, 2003; 108(15): 1779 - 1783. [Full Text] [PDF]
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 Potential Benefit from ICDs or Amiodarone After MI Journal Watch (General), November 30, 2001; 2001(1130): 4 - 4. [Full Text]
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