Cost-Effectiveness Analysis of Invasive and Noninvasive Tests in High Risk Patients Treated With Amiodarone After Acute Myocardial Infarction

Objectives. We sought to evaluate 1) the cost-effectiveness of amiodarone therapy in postinfarction patients; and 2) the influence of alternative diagnostic strategies (noninvasive only vs. noninvasive and electrophysiologic testing) on survival benefit and cost-effectiveness ratio of amiodarone therapy. Background. The cost-effectiveness of amiodarone therapy in postinfarction patients is still unknown, and no study has determined which diagnostic strategy should be used to maximize amiodarone survival benefit while improving its cost-effectiveness ratio. Methods. We designed postinfarction scenario wherein heart rate variability analysis on 24-h Holter monitoring was used as screening test for 2-year amiodarone therapy in cohort of survivors (mean age 57 years) of recent myocardial infarction. Three different therapeutic strategies were compared: 1) no amiodarone; 2) amiodarone in patients with depressed heart rate variability; 3) amiodarone in patients with depressed heart rate variability and positive programmed ventricular stimulation. Total variable costs and quality-adjusted life expectancy during 20-year period were predicted with use of Markov simulation model. Costs and charges were calculated with reference to an Italian and American hospital. Results. Amiodarone therapy in patients with depressed heart rate variability and positive programmed ventricular stimulation was dominated by blend of the two alternatives. Compared with the no-treatment strategy, the incremental cost-effectiveness ratio of amiodarone therapy in patients with depressed heart rate variability was $10,633 and $39,422 per gained quality-adjusted life-year using Italian costs and American charges, respectively. Conclusions. Compared with noninterventional option, amiodarone prescription in all patients with depressed heart rate variability seems to be more appropriate approach than the alternative based on the combined use of heart rate variability and electrophysiologic study.