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Green N, Chen Y, O'Mahony C, Elliott PM, Barriales-Villa R, Monserrat L, Anastasakis A, Biagini E, Gimeno JR, Limongelli G, Pavlou M, Omar RZ. A cost-effectiveness analysis of hypertrophic cardiomyopathy sudden cardiac death risk algorithms for implantable cardioverter defibrillator decision-making. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2024; 10:285-293. [PMID: 37660245 PMCID: PMC11238638 DOI: 10.1093/ehjqcco/qcad050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 08/22/2023] [Accepted: 08/31/2023] [Indexed: 09/04/2023]
Abstract
AIMS To conduct a contemporary cost-effectiveness analysis examining the use of implantable cardioverter defibrillators (ICDs) for primary prevention in patients with hypertrophic cardiomyopathy (HCM). METHODS A discrete-time Markov model was used to determine the cost-effectiveness of different ICD decision-making rules for implantation. Several scenarios were investigated, including the reference scenario of implantation rates according to observed real-world practice. A 12-year time horizon with an annual cycle length was used. Transition probabilities used in the model were obtained using Bayesian analysis. The study has been reported according to the Consolidated Health Economic Evaluation Reporting Standards checklist. RESULTS Using a 5-year SCD risk threshold of 6% was cheaper than current practice and has marginally better total quality adjusted life years (QALYs). This is the most cost-effective of the options considered, with an incremental cost-effectiveness ratio of £834 per QALY. Sensitivity analyses highlighted that this decision is largely driven by what health-related quality of life (HRQL) is attributed to ICD patients and time horizon. CONCLUSION We present a timely new perspective on HCM-ICD cost-effectiveness, using methods reflecting real-world practice. While we have shown that a 6% 5-year SCD risk cut-off provides the best cohort stratification to aid ICD decision-making, this will also be influenced by the particular values of costs and HRQL for subgroups or at a local level. The process of explicitly demonstrating the main factors, which drive conclusions from such an analysis will help to inform shared decision-making in this complex area for all stakeholders concerned.
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Affiliation(s)
- Nathan Green
- Department of Statistical Science, University College London, 1-19 Torrington Place, London WC1E 6BT, UK
| | - Yang Chen
- Institute of Health Informatics, Faculty of Population Health Sciences, University College London, London WC1E 6BT, UK
| | - Constantinos O'Mahony
- Institute of Cardiovascular Science, University College London, Gower St, London WC1E 6BT, UK
- St Bartholomew's Hospital, London EC1A 7BE, UK
| | - Perry M Elliott
- Institute of Cardiovascular Science, University College London, Gower St, London WC1E 6BT, UK
- St Bartholomew's Hospital, London EC1A 7BE, UK
| | - Roberto Barriales-Villa
- Unidad de Cardiopatías Familiares, Cardiology Service, Complexo Hospitalario Universitario A Coruña, Instituto de Investigación Biomédica de A Coruña (INIBIC, CIBERCV), A Coruña 15006, Spain
| | - Lorenzo Monserrat
- Unidad de Cardiopatías Familiares, Cardiology Service, Complexo Hospitalario Universitario A Coruña, Instituto de Investigación Biomédica de A Coruña (INIBIC, CIBERCV), A Coruña 15006, Spain
| | - Aristides Anastasakis
- Unit of Inherited and Rare Cardiovascular Diseases, Onassis Cardiac Surgery Centre, Leof. Andrea Siggrou 356, Kallithea 176 74, Greece
| | - Elena Biagini
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 9, Bologna 40138, Italy
| | - Juan Ramon Gimeno
- Cardiac Department, University Hospital Virgen Arrixaca, Murcia-Cartagenas, El Palmar, Murcia 30120, Spain
| | - Giuseppe Limongelli
- Monaldi Hospital, Second University of Naples, Via Leonardo Bianchi 1, Naples 80131, Italy
| | - Menelaos Pavlou
- Clinical Research Informatics Unit, University College London Hospitals, London NW1 2DA, UK
| | - Rumana Z Omar
- Clinical Research Informatics Unit, University College London Hospitals, London NW1 2DA, UK
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Teixeira RA, Fagundes AA, Baggio Junior JM, Oliveira JCD, Medeiros PDTJ, Valdigem BP, Teno LAC, Silva RT, Melo CSD, Elias Neto J, Moraes Júnior AV, Pedrosa AAA, Porto FM, Brito Júnior HLD, Souza TGSE, Mateos JCP, Moraes LGBD, Forno ARJD, D'Avila ALB, Cavaco DADM, Kuniyoshi RR, Pimentel M, Camanho LEM, Saad EB, Zimerman LI, Oliveira EB, Scanavacca MI, Martinelli Filho M, Lima CEBD, Peixoto GDL, Darrieux FCDC, Duarte JDOP, Galvão Filho SDS, Costa ERB, Mateo EIP, Melo SLD, Rodrigues TDR, Rocha EA, Hachul DT, Lorga Filho AM, Nishioka SAD, Gadelha EB, Costa R, Andrade VSD, Torres GG, Oliveira Neto NRD, Lucchese FA, Murad H, Wanderley Neto J, Brofman PRS, Almeida RMS, Leal JCF. Brazilian Guidelines for Cardiac Implantable Electronic Devices - 2023. Arq Bras Cardiol 2023; 120:e20220892. [PMID: 36700596 PMCID: PMC10389103 DOI: 10.36660/abc.20220892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Affiliation(s)
| | | | | | | | | | | | | | - Rodrigo Tavares Silva
- Universidade de Franca (UNIFRAN), Franca, SP - Brasil
- Centro Universitário Municipal de Franca (Uni-FACEF), Franca, SP - Brasil
| | | | - Jorge Elias Neto
- Universidade Federal do Espírito Santo (UFES), Vitória, ES - Brasil
| | - Antonio Vitor Moraes Júnior
- Santa Casa de Ribeirão Preto, Ribeirão Preto, SP - Brasil
- Unimed de Ribeirão Preto, Ribeirão Preto, SP - Brasil
| | - Anisio Alexandre Andrade Pedrosa
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | | | | | | | - Luis Gustavo Belo de Moraes
- Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brasil
| | | | | | | | | | - Mauricio Pimentel
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS - Brasil
| | | | - Eduardo Benchimol Saad
- Hospital Pró-Cardíaco, Rio de Janeiro, RJ - Brasil
- Hospital Samaritano, Rio de Janeiro, RJ - Brasil
| | | | | | - Mauricio Ibrahim Scanavacca
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | - Martino Martinelli Filho
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | - Carlos Eduardo Batista de Lima
- Hospital Universitário da Universidade Federal do Piauí (UFPI), Teresina, PI - Brasil
- Empresa Brasileira de Serviços Hospitalares (EBSERH), Brasília, DF - Brasil
| | | | - Francisco Carlos da Costa Darrieux
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | | | | | | | - Sissy Lara De Melo
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | - Eduardo Arrais Rocha
- Hospital Universitário Walter Cantídio, Universidade Federal do Ceará (UFC), Fortaleza, CE - Brasil
| | - Denise Tessariol Hachul
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | - Silvana Angelina D'Orio Nishioka
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | - Roberto Costa
- Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | - Gustavo Gomes Torres
- Hospital Universitário Onofre Lopes, Universidade Federal do Rio Grande do Norte (UFRN), Natal, RN - Brasil
| | | | | | - Henrique Murad
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brasil
| | | | | | - Rui M S Almeida
- Centro Universitário Fundação Assis Gurgacz, Cascavel, PR - Brasil
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Barker J, Li X, Khavandi S, Koeckerling D, Mavilakandy A, Pepper C, Bountziouka V, Chen L, Kotb A, Antoun I, Mansir J, Smith-Byrne K, Schlindwein FS, Dhutia H, Tyukin I, Nicolson WB, Ng GA. Machine learning in sudden cardiac death risk prediction: a systematic review. Europace 2022; 24:1777-1787. [PMID: 36201237 DOI: 10.1093/europace/euac135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/07/2022] [Indexed: 11/23/2022] Open
Abstract
AIMS Most patients who receive implantable cardioverter defibrillators (ICDs) for primary prevention do not receive therapy during the lifespan of the ICD, whilst up to 50% of sudden cardiac death (SCD) occur in individuals who are considered low risk by conventional criteria. Machine learning offers a novel approach to risk stratification for ICD assignment. METHODS AND RESULTS Systematic search was performed in MEDLINE, Embase, Emcare, CINAHL, Cochrane Library, OpenGrey, MedrXiv, arXiv, Scopus, and Web of Science. Studies modelling SCD risk prediction within days to years using machine learning were eligible for inclusion. Transparency and quality of reporting (TRIPOD) and risk of bias (PROBAST) were assessed. A total of 4356 studies were screened with 11 meeting the inclusion criteria with heterogeneous populations, methods, and outcome measures preventing meta-analysis. The study size ranged from 122 to 124 097 participants. Input data sources included demographic, clinical, electrocardiogram, electrophysiological, imaging, and genetic data ranging from 4 to 72 variables per model. The most common outcome metric reported was the area under the receiver operator characteristic (n = 7) ranging between 0.71 and 0.96. In six studies comparing machine learning models and regression, machine learning improved performance in five. No studies adhered to a reporting standard. Five of the papers were at high risk of bias. CONCLUSION Machine learning for SCD prediction has been under-applied and incorrectly implemented but is ripe for future investigation. It may have some incremental utility in predicting SCD over traditional models. The development of reporting standards for machine learning is required to improve the quality of evidence reporting in the field.
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Affiliation(s)
- Joseph Barker
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Cardiology Department, Glenfield Hospital, University Hospitals Leicester, Leicester, UK
| | - Xin Li
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- School of Engineering, University of Leicester, Leicester, UK
| | - Sarah Khavandi
- Faculty of Medicine, Imperial College School of Medicine, Imperial College London, London, UK
| | - David Koeckerling
- Division of Angiology, Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Akash Mavilakandy
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Coral Pepper
- Library and Information Service, University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | - Long Chen
- School of Computing and Mathematical Sciences, University of Leicester, Leicester, UK
| | - Ahmed Kotb
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Cardiology Department, Glenfield Hospital, University Hospitals Leicester, Leicester, UK
| | - Ibrahim Antoun
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | | | - Karl Smith-Byrne
- Cancer Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Fernando S Schlindwein
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- School of Engineering, University of Leicester, Leicester, UK
| | - Harshil Dhutia
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Cardiology Department, Glenfield Hospital, University Hospitals Leicester, Leicester, UK
| | - Ivan Tyukin
- Department of Mathematics, University of Leicester, Leicester, UK
| | - William B Nicolson
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Cardiology Department, Glenfield Hospital, University Hospitals Leicester, Leicester, UK
| | - G Andre Ng
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Cardiology Department, Glenfield Hospital, University Hospitals Leicester, Leicester, UK
- Cardiovascular Theme, National Institute for Health Research, Leicester Biomedical Research Centre, Leicester, UK
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Lu ZK, Xiong X, Lee T, Wu J, Yuan J, Jiang B. Big Data and Real-World Data based Cost-Effectiveness Studies and Decision-making Models: A Systematic Review and Analysis. Front Pharmacol 2021; 12:700012. [PMID: 34737696 PMCID: PMC8562301 DOI: 10.3389/fphar.2021.700012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 08/27/2021] [Indexed: 12/28/2022] Open
Abstract
Background: Big data and real-world data (RWD) have been increasingly used to measure the effectiveness and costs in cost-effectiveness analysis (CEA). However, the characteristics and methodologies of CEA based on big data and RWD remain unknown. The objectives of this study were to review the characteristics and methodologies of the CEA studies based on big data and RWD and to compare the characteristics and methodologies between the CEA studies with or without decision-analytic models. Methods: The literature search was conducted in Medline (Pubmed), Embase, Web of Science, and Cochrane Library (as of June 2020). Full CEA studies with an incremental analysis that used big data and RWD for both effectiveness and costs written in English were included. There were no restrictions regarding publication date. Results: 70 studies on CEA using RWD (37 with decision-analytic models and 33 without) were included. The majority of the studies were published between 2011 and 2020, and the number of CEA based on RWD has been increasing over the years. Few CEA studies used big data. Pharmacological interventions were the most frequently studied intervention, and they were more frequently evaluated by the studies without decision-analytic models, while those with the model focused on treatment regimen. Compared to CEA studies using decision-analytic models, both effectiveness and costs of those using the model were more likely to be obtained from literature review. All the studies using decision-analytic models included sensitivity analyses, while four studies no using the model neither used sensitivity analysis nor controlled for confounders. Conclusion: The review shows that RWD has been increasingly applied in conducting the cost-effectiveness analysis. However, few CEA studies are based on big data. In future CEA studies using big data and RWD, it is encouraged to control confounders and to discount in long-term research when decision-analytic models are not used.
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Affiliation(s)
- Z Kevin Lu
- Department of Clinical Pharmacy and Outcomes Sciences, University of South Carolina, Columbia, SC, United States
| | - Xiaomo Xiong
- Department of Clinical Pharmacy and Outcomes Sciences, University of South Carolina, Columbia, SC, United States
| | - Taiying Lee
- Department of Clinical Pharmacy and Outcomes Sciences, University of South Carolina, Columbia, SC, United States
| | - Jun Wu
- Department of Pharmaceutical and Administrative Sciences, Presbyterian College School of Pharmacy, Clinton, SC, United States
| | - Jing Yuan
- Department of Clinical Pharmacy, School of Pharmacy, Fudan University, Shanghai, China
| | - Bin Jiang
- Department of Administrative and Clinical Pharmacy, School of Pharmaceutical Sciences, Health Science Center, Peking University, Beijing, China
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5
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Higuera L, Holbrook R, Wherry K, Rodriguez DA, Cuesta A, Valencia J, Arcos J, López Gómez A. Comparison of cost-effectiveness of implantable cardioverter defibrillator therapy in patients for primary prevention in Latin America: an analysis using the Improve SCA study. J Med Econ 2021; 24:173-180. [PMID: 33471579 DOI: 10.1080/13696998.2021.1877451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The mortality benefit of implantable cardioverter defibrillators (ICDs) for primary prevention (PP) of sudden cardiac arrest (SCA) has been well-established, but ICD therapy remains globally underutilized. The results of the Improve SCA study showed a 49% relative risk reduction in all-cause mortality among ICD patients with 1.5 primary prevention (1.5PP) characteristics (patients with one or more risk factors, p < 0.0001). We evaluated the cost-effectiveness of ICD compared to no ICD therapy among patients with 1.5PP characteristics in three Latin American countries and analyzed the factors involved in cost-effectiveness. METHODS We used a published Markov model that compares costs and outcomes of ICD to no ICD therapy from local payers' perspective and included country-specific and disease-specific inputs from the Improve SCA study and current literature. We used WHO-recommended willingness-to-pay (WTP) thresholds to assess cost-effectiveness and compared model outcomes between countries. RESULTS Incremental costs per QALY (quality-adjusted life year) saved by ICD compared to no ICD therapy are Colombian Pesos COP$46,729,026 in Colombia, Mexican Pesos MXN$246,016 in Mexico, and Uruguayan Pesos UYU$1,213,614 in Uruguay in the base case scenario; all three figures are between 1-3-times GDP per capita for each country. One-way and probabilistic sensitivity analyses confirm the base case scenario results. Non-cardiac accumulated deaths are lower in Mexico, resulting in a comparatively increased cost-effective ICD therapy. LIMITATIONS The Improve SCA study was not randomized, so clinical results could be biased; however, measures were taken to reduce this bias. Costs and benefits were modelled beyond the timeline of direct observation in the Improve SCA study. CONCLUSIONS ICD therapy is cost-effective in Mexico and Uruguay and potentially cost-effective in Colombia for a 1.5PP population. Variability in ICER estimates by country can be explained by differences in non-cardiac deaths and cost inputs.
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Affiliation(s)
- Lucas Higuera
- Health Economics and Outcomes Research, CRHF, Medtronic plc, Mounds View, MN, USA
| | - Reece Holbrook
- Health Economics and Outcomes Research, CRHF, Medtronic plc, Mounds View, MN, USA
| | - Kael Wherry
- Health Economics and Outcomes Research, Diabetes, Medtronic plc, Northridge, CA, USA
| | - Diego A Rodriguez
- Cardiology - Electrophysiology, Fundación Cardioinfantil, Bogotá DC, Colombia
| | - Alejandro Cuesta
- Centro Cardiovascular Universitario, Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay
| | - Juan Valencia
- Reimbursement and Health Economics, Latin America, Medtronic plc, Miami, FL, USA
| | - Julián Arcos
- Clinical Affairs, Latin America, Medtronic plc, Bogotá DC, Colombia
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Holbrook R, Higuera L, Wherry K, Phay D, Hsieh YC, Lin KH, Liu YB. Implantable cardioverter defibrillator therapy is cost effective for primary prevention patients in Taiwan: An analysis from the Improve SCA trial. PLoS One 2020; 15:e0241697. [PMID: 33211698 PMCID: PMC7676667 DOI: 10.1371/journal.pone.0241697] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 10/20/2020] [Indexed: 11/30/2022] Open
Abstract
Objective Implantable cardiac defibrillators (ICDs) for primary prevention (PP) of sudden cardiac arrest (SCA) are well-established but underutilized globally. The Improve SCA study has identified a cohort of patients called 1.5 primary prevention (1.5PP) based on PP patients with the presence of certain risk factors. We evaluated the cost-effectiveness of ICD therapy compared to no ICD among the PP population and the subset of 1.5PP patients in Taiwan. Methods A Markov model was run over a lifetime time horizon from the Taiwan payer perspective. Mortality and utility estimates were obtained from the literature (PP) and the IMPROVE SCA trial (1.5PP). Cost inputs were obtained from the Taiwan National Health Insurance Administration (NHIA), Ministry of Health and Welfare. We used a willingness-to-pay (WTP) threshold of NT$2,100,000, as established through standard WTP research methods and in alignment with World Health Organization recommendations. Results The total discounted costs for ICD therapy and no ICD therapy were NT$1,664,259 and NT$646,396 respectively for PP, while they were NT$2,410,603 and NT$905,881 respectively for 1.5PP. Total discounted QALYs for ICD therapy and no ICD therapy were 6.48 and 4.98 respectively for PP, while they were 10.78 and 7.71 respectively for 1.5PP. The incremental cost effectiveness ratio was NT$708,711 for PP and NT$441,153 for 1.5PP, therefore ICD therapy should be considered cost effective for PP and highly cost effective for 1.5PP. Conclusions ICD therapy compared to no ICD therapy is cost-effective in the whole PP population and highly cost-effective in the subset 1.5PP population in Taiwan.
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Affiliation(s)
| | | | | | | | - Yu-Cheng Hsieh
- Department of Cardiology, Taichung Veterans General Hospital and National Yan-Ming University School of Medicine, Taichung, Taiwan
| | - Kuo-Hung Lin
- Department of Cardiology, China Medical Center University Hospital
| | - Yen-Bin Liu
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- * E-mail:
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Abstract
Heart failure with reduced ejection fraction (HFrEF) represents at least half of the cases of heart failure, which is a syndrome defined as the inability of the heart to supply the body's tissues with an adequate amount of blood under conditions of normal cardiac filling pressure. HFrEF is responsible for high costs and rates of mortality, morbidity, and hospital admissions, mainly in developed countries. Thus, the need for better diagnostic methods and therapeutic approaches and consequently better outcomes is clear. In this article, we review the principal aspects of pathophysiology and diagnosis of HFrEF, with focus on emerging biomarkers and on recent echocardiographic methods for the assessment of left ventricular function. Furthermore, we discuss several major developments in pharmacological and nonpharmacological treatment of HFrEF in the last years, including cardiac resynchronization therapy, implantable cardioverter defibrillators, and the recent and promising drug LCZ696, focusing on current indications, unanswered questions, and other relevant aspects.
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8
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Khairy P. Ventricular arrhythmias and sudden cardiac death in adults with congenital heart disease. Heart 2016; 102:1703-1709. [DOI: 10.1136/heartjnl-2015-309069] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 05/09/2016] [Indexed: 11/04/2022] Open
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Duncker D, Veltmann C. The Wearable Cardioverter/Defibrillator - Toy Or Tool? J Atr Fibrillation 2016; 8:1367. [PMID: 27909495 DOI: 10.4022/jafib.1367] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 12/14/2015] [Accepted: 12/16/2015] [Indexed: 12/29/2022]
Abstract
After the success story of implantable cardioverter/defibrillator systems, prevention of sudden cardiac death (SCD) remains one of the main duties in cardiology. For patients with unkown or transient risk profile for SCD, a wearable cardioverter/defibrillator (WCD) has been established for temporary and effective prevention of sudden arrhythmic death. Several studies have shown safety and efficacy of the WCD, even though randomized studies proving a mortality benefit are still lacking. This review provides an overview of actual WCD data and usage, special indications and possible risks and complications. WCD use is effective and adequate for temporary prevention of SCD in chosen populations. In particular, it provides secured time for sophisticated risk stratification to identify patients at persistent risk for SCD. Nevertheless, prospective randomized trials seem mandatory to prove a prognostic relevance and the economic value of this device.
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Affiliation(s)
- David Duncker
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, D-30625 Hannover
| | - Christian Veltmann
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, D-30625 Hannover
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Cost-Effectiveness of Cetuximab for Advanced Esophageal Squamous Cell Carcinoma. PLoS One 2016; 11:e0153943. [PMID: 27100871 PMCID: PMC4839693 DOI: 10.1371/journal.pone.0153943] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 04/06/2016] [Indexed: 01/09/2023] Open
Abstract
Background Costly biologicals in palliative oncology are emerging at a rapid pace. For example, in patients with advanced esophageal squamous cell carcinoma addition of cetuximab to a palliative chemotherapy regimen appears to improve survival. However, it simultaneously results in higher costs. We aimed to determine the incremental cost-effectiveness ratio of adding cetuximab to first-line chemotherapeutic treatment of patients with advanced esophageal squamous cell carcinoma, based on data from a randomized controlled phase II trial. Methods A cost effectiveness analysis model was applied based on individual patient data. It included only direct medical costs from the health-care perspective. Quality-adjusted life-years and incremental cost-effectiveness ratios were calculated. Sensitivity analysis was performed by a Monte Carlo analysis. Results Adding cetuximab to a cisplatin-5-fluorouracil first-line regimen for advanced esophageal squamous cell carcinoma resulted in an the incremental cost-effectiveness ratio of €252,203 per quality-adjusted life-year. Sensitivity analysis shows that there is a chance of less than 0.001 that the incremental cost-effectiveness ratio will be less than a maximum willingness to pay threshold of €40,000 per quality-adjusted life-year, which is representative for the threshold used in The Netherlands and other developed countries. Conclusions Addition of cetuximab to a cisplatin-5-fluorouracil first-line regimen for advanced esophageal squamous cell carcinoma is not cost-effective when appraised according to currently accepted criteria. Cost-effectiveness analyses using outcome data from early clinical trials (i.c. a phase II trial) enable pharmaceutical companies and policy makers to gain early insight into whether a new drug meets the current eligibility standards for reimbursement and thereby potential admittance for use in regular clinical practice.
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11
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Neuzner J. The mismatch between patient life expectancy and the service life of implantable devices in current cardioverter-defibrillator therapy: a call for larger device batteries. Clin Res Cardiol 2015; 104:456-60. [PMID: 25690935 DOI: 10.1007/s00392-014-0807-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 12/23/2014] [Indexed: 10/24/2022]
Abstract
In 2005, Bob Hauser published a paper in the Journal of the American College of Cardiology entitled "The growing mismatch between patient longevity and the service life of Implantable Cardioverter-Defibrillators". Now, nearly a decade later, I would like to perform a second look on the problem of a mismatching between ICD device service life and the survival of ICD recipients. Since 2005, the demographics of the ICD population has changed significantly. Primary prevention has become the dominant indication in defibrillator therapy and device implantation is indicated more and more in earlier stages of cardiac diseases. In former larger scale ICD trials, the patient average 5-year survival probability was in a range of 68-71%; in newer CRT-D trials in a range of 72-88%. Due to a progressively widened ICD indication and implantation preferentially performed in patients with better life expectancy, the problem of inadequate device service life is of growing importance. The early days of defibrillator therapy started with a generator volume of 145 ccm and a device service life <18 months. In this early period, the device miniaturization and extension of service life were similar challenges for the technicians. Today, we have reached a formerly unexpected extent of device miniaturization. However, technologic improvements were often preferentially translated in further device miniaturization and not in prolonging device service life. In his analysis, Bob Hauser reported a prolonged device service life of 2.3 years in ICD models with a larger battery capacity of 0.54 up to 0.69 Ah. Between 2008 and 2014, several studies had been published on the problem of ICD longevity in clinical scenarios. These analyses included "older" and currently used single chamber, dual chamber and CRT devices. The reported average 5-year device service life ranged from 0 to 75%. Assuming today technology, larger battery capacities will only result in minimal increase in device volume. Selected ICD patients may further benefit from device miniaturization-but the vast majority may much more benefit from a significant prolongation in device service life. All published cost-effectiveness analyses in ICD therapy show that device costs and device service life are the dominant determinants of the results. The performed "second look-nearly a decade later" revealed that there are still relevant limitations regarding the device service life in current defibrillator therapy. Technical improvements were preferentially transformed into device miniaturization but not into prolonging device service life. But this optimization is strongly enforced. The most feasible solution might be the use of device batteries with larger capacities. The economic burden, mainly caused by non-adequate device service life, may limit the future realization of ICD therapy in a progressively growing patient population. In the former years, physicians and device manufacturers have ignored the patient perspective in defibrillator therapy. However, it is the patient viewpoint that prolonged device service life is much more important than smaller generator size.
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Affiliation(s)
- Jörg Neuzner
- Medizinische Klinik II, Klinikum Kassel, Mönchebergstrasse 41-43, 34125, Kassel, Germany,
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Boriani G, Cimaglia P, Biffi M, Martignani C, Ziacchi M, Valzania C, Diemberger I. Cost-effectiveness of implantable cardioverter-defibrillator in today's world. Indian Heart J 2013; 66 Suppl 1:S101-4. [PMID: 24568820 DOI: 10.1016/j.ihj.2013.12.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Accepted: 12/07/2013] [Indexed: 11/18/2022] Open
Abstract
The implantable cardioverter-defibrillator (ICD) is an example of an effective intervention with high up-front costs and delayed benefits. It has become a proven and well-accepted therapy not only for secondary but also for primary prevention of sudden cardiac death in patients with ischemic and non-ischemic heart disease. In recent years, the international guidelines have extended the indications to the prophylactic ICD, increasing the number of eligible patients and, together, the financial challenges of a widespread implementation. In this article, we review the available economic tools that can help address the ICD cost issue. We think that the awareness of such knowledge may facilitate dialogues between physicians, administrators and policy-makers, and help foster rational decision making.
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Affiliation(s)
- Giuseppe Boriani
- Institute of Cardiology, Department of Experimental, Diagnostic and Specialty Medicine, University Hospital Sant' Orsola-Malpighi, Via Massarenti 9, 40138 Bologna, Italy.
| | - Paolo Cimaglia
- Institute of Cardiology, Department of Experimental, Diagnostic and Specialty Medicine, University Hospital Sant' Orsola-Malpighi, Via Massarenti 9, 40138 Bologna, Italy
| | - Mauro Biffi
- Institute of Cardiology, Department of Experimental, Diagnostic and Specialty Medicine, University Hospital Sant' Orsola-Malpighi, Via Massarenti 9, 40138 Bologna, Italy
| | - Cristian Martignani
- Institute of Cardiology, Department of Experimental, Diagnostic and Specialty Medicine, University Hospital Sant' Orsola-Malpighi, Via Massarenti 9, 40138 Bologna, Italy
| | - Matteo Ziacchi
- Institute of Cardiology, Department of Experimental, Diagnostic and Specialty Medicine, University Hospital Sant' Orsola-Malpighi, Via Massarenti 9, 40138 Bologna, Italy
| | - Cinzia Valzania
- Institute of Cardiology, Department of Experimental, Diagnostic and Specialty Medicine, University Hospital Sant' Orsola-Malpighi, Via Massarenti 9, 40138 Bologna, Italy
| | - Igor Diemberger
- Institute of Cardiology, Department of Experimental, Diagnostic and Specialty Medicine, University Hospital Sant' Orsola-Malpighi, Via Massarenti 9, 40138 Bologna, Italy
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