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Objectives
Assessing the cost-effectiveness credentials of this intervention in patients with concomitant atrial fibrillation (AF) and heart failure (HF) compared with usual medical therapy.
Design
A Markov model comprising two health states (ie, alive or dead) was constructed. The transition probabilities were directly derived from published Kapl...
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We simulated mode...
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Citations
... It is important to note that the benefit of early TAVI primarily lies in reducing the incidence of HF-a condition that is associated with high hospitalisation rates, readmission, deaths and healthcare costs. 16 For example, our model showed that per 10 000 patients treated, 1629 patients would avoid HF during their lifetime; this avoidance of HF would result in gains of 3.02 QALYs and 3.99 LYs per patient, and additional healthcare costs of up to $A3.66 billion in the Australian healthcare system perspective. ...
Objective
Aortic stenosis (AS) is one of the most common acquired cardiac valvular diseases. The success of transcatheter aortic valve implantation (TAVI) for severe AS has led to increasing interest in its use to earlier disease—moderate AS (MAS).
Design
Model-based study using a Markov microsimulation technique to evaluate the long-term costs and benefits associated with ‘early’ TAVI. Key data inputs were sourced from the international literature and costs were obtained from Australian sources.
Setting
Australian health care system perspective.
Participants
10 000 hypothetical MAS patients with or without left ventricular diastolic dysfunction or impaired left ventricular ejection fraction.
Intervention
Comparing early TAVI to medical management over a life time horizon for MAS patients aged >65 years. We evaluated the cost-effectiveness of offering early TAVI in five scenarios (10%, 25%, 50%, 75% and 90% take-up rates).
Primary and secondary outcome measures
The primary outcome measure is quality-adjusted life years (QALY) gained and the incremental cost–utility ratio (ICUR). Secondary outcomes are life-years gained and the number of heart failure case avoided.
Results
Offering early TAVI for MAS patients resulted in both higher healthcare costs and greater benefits (an increase of 3.02 QALYs or 3.99 life-years) per person treated. The ICUR was around $A10 867 and $A11 926 per QALY gained for all five scenarios, with the total cost of early TAVI to the healthcare system being anticipated to be up to $A3.66 billion. Sensitivity analyses indicated a 100% probability of being cost-effective with a willingness to pay threshold of $A50 000/QALY. The benefits remained, even with assumptions of high levels of repeat valve replacement after TAVI.
Conclusion
While ongoing randomised controlled trials will define the benefit of TAVI to MAS patients, these results suggest that this intervention is likely to be cost-effective.
... Despite advances in ablation and procedure techniques, costeffectiveness analyses of ablation-based rhythm control therapy have yielded heterogeneous conclusion that depend on the analysis model, parameters derived from the literature, and study population (17,18,(35)(36)(37)(38)(39). Recently, Chew et al. (18) reported randomized trialbased economic evaluation results suggesting that catheter ablation of AF is economically attractive compared with drug therapy with an ICER of $57,893/QALY using the conventional WTP threshold of $100,000/QALY in the US. ...
Background:
Ablation-based treatment has emerged as an alternative rhythm control strategy for symptomatic atrial fibrillation (AF). Recent studies have demonstrated the cost-effectiveness of ablation compared with medical therapy in various circumstances. We assessed the economic comparison between ablation and medical therapy based on a nationwide real-world population.
Methods and findings:
For 192,345 patients with new-onset AF (age ≥ 18 years) identified between August 2015 and July 2018 from the Korean Health Insurance Review and Assessment Service (HIRA) database, medical resource use data were collected to compare AF patients that underwent ablation (N = 2,131) and those administered antiarrhythmic drugs (N = 8,048). Subsequently, a Markov chain Monte Carlo model was built. The patients had at least one risk factor for stroke, and the base-case used a 20-year time horizon, discounting at 4.5% annually. Transition probabilities and costs were estimated using the present data, and utilities were derived from literature review. The costs were converted to US $ (2019). Sensitivity analyses were performed using probabilistic and deterministic methods. The net costs and quality-adjusted life years (QALY) for antiarrhythmic drugs and ablation treatments were $37,421 and 8.8 QALYs and $39,820 and 9.3 QALYs, respectively. Compared with antiarrhythmic drugs, incremental cost-effectiveness ratio of ablation was $4,739/QALY, which is lower than the willingness-to-pay (WTP) threshold of $32,000/QALY.
Conclusion:
In symptomatic AF patients with a stroke risk under the age of 75 years, ablation-based rhythm control is potentially a more economically attractive option compared with antiarrhythmic drug-based rhythm control in Korea.
... They concluded that AHF represented highrisk patients with higher mortality and likelihood of re-hospitalization during the same follow-up period than chronic stable HF. The treatment goal of HF is not only to improve symptoms and quality of life but also to prevent and delay the development of cardiac remodeling by targeting the mechanism of cardiac remodeling to reduce the mortality and hospitalization rate of patients with HF (31). Delayed diagnosis of AHF worsens prognosis by increasing the time to initiate initial treatment, and this delay may be associated with increased morbidity and mortality (32). ...
Background
The risk factors for acute heart failure (AHF) vary, reducing the accuracy and convenience of AHF prediction. The most common causes of AHF are coronary heart disease (CHD). A short-term clinical predictive model is needed to predict the outcome of AHF, which can help guide early therapeutic intervention. This study aimed to develop a clinical predictive model for 1-year prognosis in CHD patients combined with AHF.
Materials and methods
A retrospective analysis was performed on data of 692 patients CHD combined with AHF admitted between January 2020 and December 2020 at a single center. After systemic treatment, patients were discharged and followed up for 1-year for major adverse cardiovascular events (MACE). The clinical characteristics of all patients were collected. Patients were randomly divided into the training ( n = 484) and validation cohort ( n = 208). Step-wise regression using the Akaike information criterion was performed to select predictors associated with 1-year MACE prognosis. A clinical predictive model was constructed based on the selected predictors. The predictive performance and discriminative ability of the predictive model were determined using the area under the curve, calibration curve, and clinical usefulness.
Results
On step-wise regression analysis of the training cohort, predictors for MACE of CHD patients combined with AHF were diabetes, NYHA ≥ 3, HF history, Hcy, Lp-PLA2, and NT-proBNP, which were incorporated into the predictive model. The AUC of the predictive model was 0.847 [95% confidence interval (CI): 0.811–0.882] in the training cohort and 0.839 (95% CI: 0.780–0.893) in the validation cohort. The calibration curve indicated good agreement between prediction by nomogram and actual observation. Decision curve analysis showed that the nomogram was clinically useful.
Conclusion
The proposed clinical prediction model we have established is effective, which can accurately predict the occurrence of early MACE in CHD patients combined with AHF.
... A 2019 study performed in Australia by Gao and Moodie looked at the cost-effectiveness of catheter ablation versus medical therapy in patients with both AF and heart failure, yielding an ICER that was above the WTP threshold. 16 However, that study only evaluated the impact of reduced mortality. Therefore, again, healthcare facility use and other clinical events were not accounted for, which are important variables with significant effects on overall cost and quality of life. ...
Randomized evidence supports early rhythm control strategy as treatment for atrial fibrillation and catheter ablation outperforms medical therapy in terms of effectiveness when studied as 1st and 2nd line treatment. Despite evidence consistently showing that catheter ablation treatment is superior to medical therapy in the majority, only a small proportion of patients receive ablation and some after a prolonged trial of ineffective medical therapy. Health economics research in electrophysiology remains limited but is recognised as being important to influence positive change to ensure early access to ablation services for all eligible patients. Such information has informed the updated recommendations from the recently published National Institute for Health and Care Excellence (NICE) clinical guideline on the diagnosis and management of atrial fibrillation but increased awareness is needed to drive real world adoption and ensure patients are quickly referred to specialists. In this article, economic evaluations on catheter ablation versus medical therapy are reviewed.
... With the further study of the mechanism of AF, new ablation technologies (including new ablation energy: cryotherapy, high-frequency ultrasound, laser, etc.) are emerging [15,16]. Continuous improvement of ablation methods and devices, combined with drug therapy and minimally invasive surgery or with other comprehensive measures, will increase the benefits for patients with AF [17]. In this study, we conducted a meta-analysis on the randomized controlled trials of catheter ablation (CA) and traditional medical therapy in treating patients with HF and AF to provide a reference for clinical practice. ...
Objective:
To compare the efficacy of catheter ablation and medical therapy in patients with heart failure and atrial fibrillation.
Methods:
We searched randomized controlled trials comparing catheter ablation versus medical therapy for heart failure and atrial fibrillation through PubMed, MEDLINE, Embase, Cochrane Clinical Trials Database, Web of Science, and China National Knowledge Infrastructure. Articles were investigated for their methodological quality using the Cochrane Collaboration risk of the bias assessment tool. Forest plots, funnel plots, and sensitivity analysis were also performed on the included articles. Results were expressed as risk ratio (RR) and mean difference (MD) with 95% confidence intervals.
Results:
Nine (9) studies were included in this study with 1131 patients. Meta-analysis showed a reduction in all-cause mortality from catheter ablation compared with medical therapy (RR = 0.53, 95% CI = 0.37 to 0.76; P=0.0007) and improved left ventricular ejection fraction (LVEF) (MD = 6.45, 95% CI = 3.49 to 9.41; P < 0.0001), 6-minute walking time (6MWT) (MD = 28.32, 95% CI = 17.77 to 38.87; P < 0.0001), and Minnesota Living with Heart Failure Questionnaire (MLHFQ) score (MD = 8.19, 95% CI = 0.30 to 16.08; P=0.04).
Conclusion:
Catheter ablation had a better improvement than medical treatment in left ventricular ejection fraction, cardiac function, and exercise ability for atrial fibrillation and heart failure patients.
... In clinical practice, it is possible that patients may be managed differently depending on their age and other comorbid conditions. This model did not account for inevitable crossover from medical therapy to catheter ablation, which is common in clinical practice (i.e., 27.5% of patients crossed over from medical therapy to ablation in the CABANA study), 34 but this was done to ensure a clear comparison of the ablation and medical therapy treatment strategies to assess cost-effectiveness. It is important to note that in the current environment, worsened by the coronavirus pandemic, it is not unusual to find patients deemed suitable for catheter ablation to remain on the waiting list for the procedure over a prolonged period, over three cycles (9 months) duration as per model. ...
Introduction
Research evidence has shown that catheter ablation is a safe and superior treatment for atrial fibrillation (AF) compared to medical therapy, but real-world practice has been slow to adopt an early interventional approach. This study aims to determine the cost effectiveness of catheter ablation compared to medical therapy from the perspective of the United Kingdom.
Methods
A patient-level Markov health-state transition model was used to conduct a cost-utility analysis. The population included patients previously treated for AF with medical therapy, including those with heart failure (HF), simulated over a lifetime horizon. Data sources included published literature on utilization and cardiovascular event rates in real world patients, a systematic literature review and meta-analysis of randomized controlled trials for AF recurrence, and publicly available government data/reports on costs.
Results
Catheter ablation resulted in a favorable incremental cost-effectiveness ratio (ICER) of £8,614 per additional quality adjusted life years (QALY) gained when compared to medical therapy. More patients in the medical therapy group failed rhythm control at any point compared to catheter ablation (72% vs 24%) and at a faster rate (median time to treatment failure: 3.8 vs 10 years). Additionally, catheter ablation was estimated to be more cost-effective in patients with AF and HF (ICER = £6,438) and remained cost-effective over all tested time horizons (10, 15, and 20 years), with the ICER ranging from £9,047–£15,737 per QALY gained.
Conclusion
Catheter ablation is a cost-effective treatment for atrial fibrillation, compared to medical therapy, from the perspective of the UK National Health Service.
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... Gao et al reported an incremental cost-effectiveness ratio (ICER) of $55 942 Australian dollars (AUD)/qualityadjusted life-years (QALY) which was felt not to be cost-effective at an ICER threshold of $50 000 AUD/ QALY. 16 Chew et al reported an ICER of $38 496 USD/ QALY which was felt to be cost-effective at a higher threshold of $100 000 USD/QALY, with a reasonable chance (75%) of being cost-effective at the $50 000 USD/QALY threshold. 17 Variations in the conclusions and modeling decisions of these 2 studies-for example, the use of baseline health utilities from AF, as opposed to HF, populations in Chew et al, and the assumption of a utility increment of 0.08 associated with maintenance of sinus rhythm; the use of background lifetime mortality rates extrapolated from CASTLE-AF in both studies-necessitate additional studies to ensure convergence (or to explore divergence) of findings across different settings and conditions. ...
... 39 While many have indicated that CA in the regular AF population may be attractive, some of these cost-effectiveness analyses presumed a benefit on stroke risk from the restoration of sinus rhythm, which was not borne out by the recent CABANA trial. 10 In patients with HF and comorbid AF, only 2 previous costeffectiveness analyses have examined the cost-utility of CA. 16,17 Gao et al, 2019, produced a model similar to our own, but concluded that their base case ICER was unfavorable, at $55 942 AUD/QALY. One difference appears to have been different means of estimating mortality in our respective models. ...
Background
Recent trials comparing catheter ablation to medical therapy in patients with heart failure (HF) with symptomatic atrial fibrillation despite first‐line management have demonstrated a reduction in adverse outcomes. We performed an economic evaluation to estimate the cost‐utility of catheter ablation as second line therapy in patients with HF with reduced ejection fraction.
Methods and Results
A Markov model with health states of alive, dead, and alive with amiodarone toxicity was constructed, using the perspective of the Canadian healthcare payer. Patients in the alive states were at risk of HF and non‐HF hospitalizations. Parameters were obtained from randomized trials and Alberta health system data for costs and outcomes. A lifetime time horizon was adopted, with discounting at 3.0% annually. Probabilistic and 1‐way sensitivity analyses were performed. Costs are reported in 2018 Canadian dollars. A patient treated with catheter ablation experienced lifetime costs of $64 960 and 5.63 quality‐adjusted life‐years (QALY), compared with $49 865 and 5.18 QALYs for medical treatment. The incremental cost‐effectiveness ratio was $35 360/QALY (95% CI, $21 518–77 419), with a 90% chance of being cost‐effective at a willingness‐to‐pay threshold of $50 000/QALY. A minimum mortality reduction of 28%, or a minimum duration of benefit of >1 to 2 years was required for catheter ablation to be attractive at this threshold.
Conclusions
Catheter ablation is likely to be cost‐effective as a second line intervention for patients with HF with symptomatic atrial fibrillation, with incremental cost‐effectiveness ratio $35 360/QALY, as long as over half of the relative mortality benefit observed in extant trials is borne out in future studies.
... A longer time horizon may have shown an even greater reduction in HCU, as suggested by previous studies. 19 ...
Background
Patients with persistent atrial fibrillation (AF) undergoing catheter‐based AF ablation have lower success rates than those with paroxysmal AF. We compared healthcare use and clinical outcomes between patients according to their AF subtypes.
Methods and Results
Consecutive patients undergoing AF ablation were prospectively identified from a population‐based registry in Ontario, Canada. Via linkage with administrative databases, we performed a retrospective analysis comparing the following outcomes between patients with persistent and paroxysmal AF: healthcare use (defined as AF‐related hospitalizations/emergency room visits), periprocedural complications, and mortality. Multivariable Poisson modeling was performed to compare the rates of AF‐related and all‐cause hospitalizations/emergency room visits in the year before versus after ablation. Between April 2012 and March 2016, there were 3768 consecutive patients who underwent first‐time AF ablation, of whom 1040 (27.6%) had persistent AF. The mean follow‐up was 1329 days. Patients with persistent AF had higher risk of AF‐related hospitalization/emergency room visits (hazard ratio [HR], 1.21; 95% CI, 1.09–1.34), mortality (HR, 1.74; 95% CI, 1.15–2.63), and periprocedural complications (odds ratio, 1.36; 95% CI, 1.02–1.75) than those with paroxysmal AF. In the overall cohort, there was a 48% reduction in the rate of AF‐related hospitalization/emergency room visits in the year after versus before ablation (rate ratio [RR], 0.52; 95% CI, 0.48–0.56). This reduction was observed for patients with paroxysmal (RR, 0.45; 95% CI, 0.41–0.50) and persistent (RR, 0.74; 95% CI, 0.63–0.87) AF.
Conclusions
Although patients with persistent AF had higher risk of adverse outcomes than those with paroxysmal AF, ablation was associated with a favorable reduction in downstream AF‐related healthcare use, irrespective of AF type.
... It is the main target organ of FGF-23 [14] . FGF-23 is linked to the onset of many cardiovascular diseases, and current research has confirmed [15] that elevated levels of FGF-23 are significantly associated with left ventricular hypertrophy, hypertension, cardiogenic death, and all-cause death. Research shows [16] that high levels of FGF-23 are an independent predictor of cardiovascular events. ...
Background:
The incidence and prevalence of atrial fibrillation are increasing each year, and this condition is one of the most common clinical arrhythmias.
Aim:
To investigate the levels and significance of serum fibroblast growth factor 23 (FGF-23) and miR-208b in patients with atrial fibrillation and their relationship with prognosis.
Methods:
From May 2018 to October 2019, 240 patients with atrial fibrillation were selected as an observation group, including 134 with paroxysmal atrial fibrillation and 106 with persistent atrial fibrillation; 150 patients with healthy sinus rhythm were selected as a control group. The serum levels of FGF-23 and miR-208b in the two groups were measured. In the observation group, cardiac parameters were determined by echocardiography.
Results:
The serum levels of FGF-23 and miR-208b in the observation group were 210.20 ± 89.60 ng/mL and 5.30 ± 1.22 ng/mL, which were significantly higher than the corresponding values in the control group (P < 0.05). In the observation group, the serum levels of FGF-23 and miR-208b in patients with persistent atrial fibrillation were 234.22 ± 70.05 ng/mL and 5.83 ± 1.00 ng/mL, which were significantly higher than the corresponding values in patients with paroxysmal atrial fibrillation (P < 0.05). The left atrial dimension (LAD) of patients with persistent atrial fibrillation was 38.81 ± 5.11 mm, which was significantly higher than that of patients with paroxysmal atrial fibrillation (P > 0.05). The serum levels of FGF-23 and miR-208b were positively correlated with the LAD (r = 0.411 and 0.382, P < 0.05). In the observation group, the serum levels of FGF-23 and miR-208b in patients with a major cardiovascular event (MACE) were 243.30 ± 72.29 ng/mL and 6.12 ± 1.12 ng/mL, which were significantly higher than the corresponding values in patients without a MACE (P < 0.05).
Conclusion:
The serum levels of FGF-23 and miR-208b are increased in patients with atrial fibrillation and are related to the type of disease, cardiac parameters, and prognosis.
Atrial fibrillation (AF) and heart failure are common overlapping cardiovascular disorders. Despite important therapeutic advances over the past several decades, controversy persists about whether a rate control or rhythm control approach constitutes the best option in this population. There is also considerable debate about whether antiarrhythmic drug therapy or ablation is the best approach when rhythm control is pursued. A brief historical examination of the literature addressing this issue will be performed. An analysis of several important clinical outcomes observed in the prospective, randomized studies, which have compared AF ablation to non‐ablation treatment options, will be discussed. This review will conclude with recommendations to guide clinicians on the status of AF ablation as a treatment option when considering management options in heart failure patients with atrial fibrillation.
