Cost-Effectiveness of New Oral Anticoagulants Compared with Warfarin in Preventing Stroke and Other Cardiovascular Events in Patients with Atrial Fibrillation

Coyle, Doug; Coyle, Kathryn; Cameron, Chris; Lee, Karen; Kelly, Shannon; Steiner, Sabine; Wells, George

doi:10.1016/j.jval.2013.01.009

Cited by 135 publications

(97 citation statements)

References 30 publications

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“…[189][190][191] Dabigatran and argatroban directly inhibit thrombin, preventing the formation of fibrin from fibrinogen. 192 Although the attractiveness of direct thrombin inhibitors is bolstered by more predictable pharmacokinetics, lack of requirement for routine laboratory monitoring, fewer drug-drug interactions, and possibly increased cost-effectiveness compared with warfarin, 193 the safety and efficacy of intravenous alteplase in patients who have been taking dabigatran are not well studied. Furthermore, if hemorrhages occur, management strategies and reversal of anticoagulation are still controversial.…”

Section: Direct Thrombin Inhibitor (Dabigatran and Argatroban)mentioning

confidence: 99%

Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke

Demaerschalk¹,

Kleindorfer²,

Adeoye³

et al. 2016

Stroke

586

237

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Purpose-To critically review and evaluate the science behind individual eligibility criteria (indication/inclusion and contraindications/exclusion criteria) for intravenous recombinant tissue-type plasminogen activator (alteplase) treatment in acute ischemic stroke. This will allow us to better inform stroke providers of quantitative and qualitative risks associated with alteplase administration under selected commonly and uncommonly encountered clinical circumstances and to identify future research priorities concerning these eligibility criteria, which could potentially expand the safe and judicious use of alteplase and improve outcomes after stroke. Methods-Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association Stroke Council's Scientific Statement Oversight Committee and the American Heart Association's Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge and, when appropriate, formulated recommendations using standard American Heart Association criteria. All members of the writing group had the opportunity to comment on and approved the final version of this document. The document underwent extensive American Heart Association internal peer review, Stroke The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on September 24, 2015, and the American Heart Association Executive Committee on October 5, 2015. A copy of the document is available at http://my.americanheart.org/statements by selecting either the "By Topic" link or the "By Publication Date" link. To purchase additional reprints, call 843-216-2533 or e-mail kelle.ramsay@ wolterskluwer.com.The online-only Data Supplement, which contains literature search strategies and Figures A, B, and C, is available with this article at http://circ. ahajournals.org/lookup/suppl/doi:10.1161/STR.0000000000000086/-/DC1.The American Heart Association requests that this document be cited as follows: Demaerschalk BM, Kleindorfer DO, Adeoye OM, Demchuk AM, Fugate JE, Grotta JC, Khalessi AA, Levy EI, Palesch YY, Prabhakaran S, Saposnik G, Saver JL, Smith EE; on behalf of the American Heart Association Stroke Council and Council on Epidemiology and Prevention. Scientific rational...

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Section: Direct Thrombin Inhibitor (Dabigatran and Argatroban)mentioning

confidence: 99%

Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke

Demaerschalk¹,

Kleindorfer²,

Adeoye³

et al. 2016

Stroke

586

237

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“…The appeal of direct thrombin inhibitors compared to traditional vitamin K antagonists is multifactorial: more predictable pharmacokinetics, lack of requirement for routine laboratory monitoring, fewer drug-drug interactions, and possibly increased cost-effectiveness. 33 The safety and efficacy of IV rtPA in patients who have been taking direct thrombin inhibitors is not well studied. Furthermore, if hemorrhages do occur, management strategies and reversal of anticoagulation are still controversial.…”

Section: Direct Thrombin Inhibitorsmentioning

confidence: 99%

Absolute and Relative Contraindications to IV rt-PA for Acute Ischemic Stroke

Fugate

Rabinstein

2015

The Neurohospitalist

145

114

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Most of the contraindications to the administration of intravenous (IV) recombinant tissue plasminogen activator (rtPA) originated as exclusion criteria in major stroke trials. These were derived from expert consensus for the National Institute of Neurological Disorders and Stroke (NINDS) trial. Despite the fact that the safety and efficacy of IV rtPA has been repeatedly confirmed in large international observational studies over the past 20 years, most patients with acute ischemic stroke disappointingly still do not receive thrombolytic treatment. Some of the original exclusion criteria have proven to be unnecessarily restrictive in real-world clinical practice. It has been suggested that application of relaxed exclusion criteria might increase the IV thrombolysis rate up to 20% with comparable outcomes to thrombolysis with more conventional criteria. We review the absolute and relative contraindications to IV rtPA for acute ischemic stroke, discussing the underlying rationale and evidence supporting these exclusion criteria.

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“…To simplify the model, we made several assumptions that are consistent with those in previous cost-effectiveness analyses of anticoagulants for stroke prevention in AF 9,12 : (1) the efficacy of treatment remained constant over time unless patients discontinued treatment; (2) after an intracranial hemorrhage or major bleed, patients would switch to aspirin; and (3) patients who had a recurrent stroke or intracranial hemorrhage could only move to a health state with similar or greater disability; for example, patients with a mild stroke could develop a moderate stroke but not vice-versa.…”

Section: Assumptionsmentioning

confidence: 99%

“…The first-year costs for ischemic stroke and intracranial hemorrhage came from studies of stroke costs 35,36 and cost-effectiveness of anticoagulants for stroke prevention. 12,33 Subsequent year costs were 60% of the firstyear costs, based on long-term costing of stroke. 33,37 The analysis used …”

Section: Costs and Utilitiesmentioning

confidence: 99%

Potential Cost-Effectiveness of Ambulatory Cardiac Rhythm Monitoring After Cryptogenic Stroke

Yong

Thavorn

Hoch

et al. 2016

Stroke

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Background and Purpose-Prolonged ambulatory ECG monitoring after cryptogenic stroke improves detection of covert atrial fibrillation, but its long-term cost-effectiveness is uncertain. Methods-We estimated the cost-effectiveness of noninvasive ECG monitoring in patients aged ≥55 years after a recent cryptogenic stroke and negative 24-hour ECG. A Markov model used observed rates of atrial fibrillation detection and anticoagulation from a randomized controlled trial (EMBRACE) and the published literature to predict lifetime costs and effectiveness (ischemic strokes, hemorrhages, life-years, and quality-adjusted life-years [QALYs]) for 30-day ECG (primary analysis) and 7-day or 14-day ECG (secondary analysis), when compared with a repeat 24-hour ECG. Results-Prolonged ECG monitoring (7, 14, or 30 days) was predicted to prevent more ischemic strokes, decrease mortality, and improve QALYs. If anticoagulation reduced stroke risk by 50%, 30-day ECG (at a cost of USD $447) would be highly cost-effective ($2000 per QALY gained) for patients with a 4.5% annual ischemic stroke recurrence risk. Costeffectiveness was sensitive to stroke recurrence risk and anticoagulant effectiveness, which remain uncertain, especially at higher costs of monitoring. Shorter duration (7 or 14 days) monitoring was cost saving and more effective than an additional 24-hour ECG; its cost-effectiveness was less sensitive to changes in ischemic stroke risk and treatment effect. Conclusions-After a cryptogenic stroke, 30-day ECG monitoring is likely cost-effective for preventing recurrent strokes; 14-day monitoring is an attractive value alternative, especially for lower risk patients. These results strengthen emerging recommendations for prolonged ECG monitoring in secondary stroke prevention. Cost-effectiveness in practice will depend on careful patient selection.

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Cost-Effectiveness of New Oral Anticoagulants Compared with Warfarin in Preventing Stroke and Other Cardiovascular Events in Patients with Atrial Fibrillation

Cited by 135 publications

References 30 publications

Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke

Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke

Absolute and Relative Contraindications to IV rt-PA for Acute Ischemic Stroke

Potential Cost-Effectiveness of Ambulatory Cardiac Rhythm Monitoring After Cryptogenic Stroke

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