doi: 10.1161/hc5001.100794
(Circulation. 2001;104:3039.)
© 2001 American Heart Association, Inc.
Clinical Investigation and Reports |
Cost-Effectiveness of Coronary Stenting in Acute Myocardial Infarction
Results From the Stent Primary Angioplasty in Myocardial Infarction (Stent-PAMI) Trial
From the Cardiovascular Data Analysis Center (D.J.C., D.A.T., R.B.) and the Cardiovascular Division (D.J.C.), Beth Israel Deaconess Medical Center, Boston, Mass; Mid-Carolina Cardiology, Charlotte, NC (D.A.C.); Institut Cardiovasculaire Paris Sud, Antony, France (M.C.M.); Lenox Hill Hospital, New York, NY (G.W.S.); and the Division of Cardiology, William Beaumont Hospital, Royal Oak, Mich (C.L.G.).
Correspondence to David J. Cohen, MD, MSc, Cardiovascular Division, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215. E-mail djc{at}hsph.harvard.edu
Background— Although several randomized trials have demonstrated that coronary stenting improves angiographic and clinical outcomes for patients with acute myocardial infarction (AMI), the cost-effectiveness of this practice is unknown. The objective of the present study was to evaluate the long-term costs and cost-effectiveness (C/E) of coronary stenting compared with primary balloon angioplasty as treatment for AMI.
Methods and Results— Between December 1996 and November 1997, 900 patients with AMI were randomized to undergo balloon angioplasty (PTCA, n=448) or coronary stenting (n=452). Detailed resource utilization and cost data were collected for each patient’s initial hospitalization and for 1 year after randomization. Compared with conventional PTCA, stenting increased procedural costs by 
$2000 per patient ($6538±1778 versus $4561±1598, P<0.001). During the 1-year follow-up period, stenting was associated with significant reductions in the need for repeat revascularization and rehospitalization. Although follow-up costs were significantly lower with stenting ($3613±7743 versus $4592±8198, P=0.03), overall 1-year costs remained $1000/patient higher with stenting than with PTCA ($20 571±10 693 versus 19 595±10 990, P=0.02). The C/E ratio for stenting compared with PTCA was $10 550 per repeat revascularization avoided. In analyses that incorporated recent changes in stent technology and pricing, the 1-year cost differential fell to <$350/patient, and the C/E ratio improved to $3753 per repeat revascularization avoided. The cost-utility ratio for primary stenting was <$50 000 per quality-adjusted life year gained only if stenting did not increase 1-year mortality by >0.2% compared with PTCA.
Conclusions— As performed in Stent-PAMI, primary stenting for AMI increased 1-year medical care costs compared with primary PTCA. The overall cost-effectiveness of primary stenting depends on the societal value attributed to avoidance of symptomatic restenosis, as well as on the relative mortality rates of primary PTCA and stenting.
Key Words: myocardial infarction • angioplasty • stents • cost-benefit analysis
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