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LAA closure, novel oral anticoagulants cost-effective options for nonvalvular AF
Both left atrial appendage closure with the Watchman device and novel oral anticoagulants are cost-effective compared with warfarin for stroke prevention in patients with nonvalvular atrial fibrillation. Over a lifetime, however, left atrial appendage closure appears to be the most cost-effective, researchers reported in a new study.
Researchers developed a Markov model to assess the cost-effectiveness of warfarin, novel oral anticoagulants and left atrial appendage (LAA) closure with the Watchman device (Boston Scientific). Patients included in the study were aged at least 70 years and had moderate risk for bleeding and stroke.
LAA closure was more expensive than warfarin in the first year after the procedure, but patients who received LAA closure gained more quality-adjusted life-years (QALY) compared with patients who received warfarin at 3 years, and LAA closure became cost-effective vs. warfarin at 7 years ($42,994/QALY). By year 10, LAA closure was more effective and less costly than warfarin, and this dominance persisted for the duration of the 20-year time interval of the study. LAA closure provided an additional 0.506 life-years and 0.638 QALY over a lifetime compared with warfarin.
Novel oral anticoagulants were more effective than warfarin at 1 year, and were cost-effective vs. warfarin at 16 years ($48,446/QALY). Novel oral anticoagulants did not maintain cost-effectiveness vs. warfarin during the 20-year period, although the incremental cost-effectiveness ratio decreased consistently over time, resulting in a cost per QALY at 20 years of $40,602.
In the first year, LAA closure was more expensive than novel oral anticoagulants, but by year 5, LAA closure was more cost-effective ($20,892 vs. $20,924) and more effective (3.455 QALY vs. 3.448 QALY). LAA closure maintained this dominance over novel oral anticoagulants for the duration of the 20-year period modeled.
The researchers estimated that LAA closure would confer an additional 0.298 life-years and 0.349 QALY compared with novel oral anticoagulants. Moreover, even when LAA closure procedure costs were doubled, LAA closure remained cost-effective vs. warfarin ($41,470/QALY at 11 years) and novel oral anticoagulants ($21,964/QALY at 10 years).
“Both [novel oral anticoagulants] and LAA [closure] with the Watchman device have the potential to change the treatment paradigm for patients with nonvalvular AF who are at risk of stroke. Both novel therapies demonstrated cost-effectiveness relative to warfarin, but only LAA [closure] demonstrated cost savings by year 10 relative to warfarin and by year 5 relative to [novel oral anticoagulants],” Vivek Y. Reddy, MD, from the electrophysiology center at Icahn School of Medicine at Mount Sinai, and colleagues wrote.
The researchers concluded that “longer-term clinical studies are needed to define more clearly the return on investment in nonpharmacologic strategies to prevent stroke in patients with AF and incorporate the findings into clinical practice guidelines and reimbursement policies.” – by Jennifer Byrne
Disclosure: Reddy and three other researchers report consulting for Boston Scientific. See the full study for the other researchers’ relevant financial disclosures.