| Summary: | The initial treatment options for patients with stable coronary artery disease include optimal medical therapy alone, or coronary revascularization with optimal medical therapy. The most common revascularization modality is percutaneous coronary intervention (PCI) with either bare metal stents (BMS) or drug-eluting stents (DES). PCI is believed to reduce recurrent angina and thereby decrease the need for additional procedures compared to optimal medical therapy alone. It remains unclear if these benefits are sufficient to offset the increased costs and small increase in adverse events associated with PCI.
The objectives of this thesis were to determine the degree of angina relief afforded by PCI and develop a tool to provide contemporary estimates of the impact of angina on quality of life. In addition, we sought to develop a comprehensive state-transition model, calibrated to real world costs and outcomes to compare the cost-effectiveness of initial medical therapy versus PCI with either BMS or DES in patients with stable coronary artery disease.
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We performed a systematic search and meta-analysis of the published literature. Although PCI was associated with an overall benefit on angina relief (odds ratio [OR] 1.69; 95% Confidence Interval [CI] 1.24-2.30), this benefit was largely attenuated in contemporary studies (OR 1.13; 95% CI 0.76-1.68). Our meta-regression analysis suggests that this observation was related to greater use of evidence-based medications in more recent trials.
Using simple linear regression, we were able to create a mapping tool that could accurately estimate utility weights from data on the Seattle Angina Question, the most common descriptive quality of life instrument used in the cardiovascular literature.
In our economic evaluation, we found that an initial strategy of PCI with a BMS was cost- effective compared to medical therapy, with an incremental cost-effectiveness ratio (ICER) of $13,271 per quality adjusted life year gained. In contrast, DES had a greater cost and lower survival than BMS and was therefore a dominated strategy.
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