Use of insertable cardiac monitors for the detection of atrial fibrillation in patients with cryptogenic stroke in the United States is cost-effective

Abstract

Objectives: Atrial fibrillation (AF) is the most common arrhythmia and a major marker of ischemic stroke risk. Early detection is crucial and, once diagnosed, anticoagulation therapy can be initiated to reduce stroke risk. The aim of this study was to assess the cost-effectiveness of employing an insertable cardiac monitor (ICM), BIOMONITOR, for the detection of AF compared to standard of care (SoC) ECG and Holter monitoring in patients with cryptogenic stroke, that is, stroke of unknown origin and where paroxysmal, silent AF is suspected. Materials and methods: A Markov model was developed which consisted of five main health states reflecting the potential lifetime evolution of the AF disease: post cryptogenic stroke (index event), subsequent mild, moderate and severe stroke, and death. Sub-states were included to track a patient's AF diagnostic status and the use of antiplatelet or anticoagulant therapy. AF detection was assumed to result in a treatment switch from aspirin to anticoagulants, except among those with a history of major bleeding. Detection yield and accuracy, clinical actions and treatment effects were derived from the literature and validated by an expert clinician. All relevant costs from a US Medicare perspective were included. Results and conclusions: An ICM-based strategy was associated with a reduction of 37 secondary ischemic strokes per 1000 patients monitored compared with SoC. Total per-patient costs with an ICM were higher (US$90,052 vs. US$85,157) although stroke-related costs were reduced. The use of an ICM was associated with a base-case incremental cost-effectiveness ratio of US$18,487 per life year gained compared with SoC and US$25,098 per quality-adjusted life year gained, below established willingness-to-pay thresholds. The conclusions were found to be robust over a range of input values. From a US Medicare perspective the use of a BIOMONITOR ICM represents a cost-effective diagnostic strategy for patients with cryptogenic stroke and suspected AF. ARTICLE HISTORY

Holter implantable con tecnología link -online- para monitorización cardiaca prolongada en pacientes con ictus previo

“…Todos los documentos analizados 10,[51][52][53] coincidieron en concluir que el uso de Holter implantable podría resultar costo-efectivo. En concreto, se exponía que, en base a la asunción de una equivalencia clínica entre todos los tipos de Holter evaluados (Reveal Linq, BioMonitor 2-AF y Confirm Rx, así como sus versiones anteriores) estos dispositivos podrían considerarse rentables en el umbral de 20.000 -30.000 libras en comparación con la intervención estándar 10,51 .…”

“…Los documentos incluidos fueron una guía de práctica clínica 51 , un estudio de evaluación económica 52 y dos revisiones sistemáticas, una centrada en analizar la rentabilidad de los Holter 53 , y otra, en la que además de analizar este aspecto, se incluía el análisis de la precisión de las pruebas de diagnóstico y de la eficacia clínica de los dispositivos 10 . La guía de práctica clínica 51 estaba basada en esta última revisión sistemática 10 .…”

“…Los estudios observacionales incluidos supusieron un total de 3.414 participantes del Norte de América y Europa occidental, y evaluaban los monitores Reveal XT y Reveal LINQ con pacientes que habían sufrido un ACV; ninguno de los estudios incluidos evaluaba los dispositivos Biomonitor 2-AF, ni Confirm Rx para pacientes tras ACV. Entre los estudios observacionales se encontraba el estudio de evaluación económica 52 que se ha incluido en la presente revisión. Por último, fueron identificados 8 estudios potencialmente relevantes que estaban en marcha en el momento de la búsqueda.…”

Mobile Cardiac Outpatient Telemetry Patch vs Implantable Loop Recorder in Cryptogenic Stroke Patients in the US – Cost-Minimization Model

“…Other studies have examined the cost-effectiveness of ILR but have used a time horizon of over a lifetime, 24,[33][34][35] which is not relevant to our one-year timeframe. No prior modeling study has examined the costs of MCOT from the US perspective.…”

Embolic Stroke of Undetermined Source: Approaches in Risk Stratification for Cardioembolism

“…However, invasive monitoring strategies provide long-term cost benefit, with ICM in patients with cryptogenic stroke found to have lower stroke-related costs with a base-case incremental costeffectiveness ratio of US$18 487 per life year gained. 87 An increase in AF detection from prolonged cardiac arrhythmia monitoring is clear. In theory, earlier and greater rates of AF detection would translate to higher rates of anticoagulation and subsequent prevention of stroke recurrence.…”