Cost-Effectiveness of Coronary Stenting and Abciximab for Patients with Acute Myocardial Infarction: Results from the CADILLAC (Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications) Trial

Background-Both stenting and the glycoprotein IIb/IIIa inhibitor abciximab improve outcomes for patients undergoing primary angioplasty for acute myocardial infarction (AMI). However, the cost-effectiveness of these strategies is unknown. Methods and Results-We performed a prospective cost-utility analysis among US participants in the CADILLAC trial. Patients with AMI (n= 1703) were randomized to stenting versus balloon angioplasty (PTCA) and abciximab versus no abciximab according to a 2-by-2 factorial design. Total 1-year costs and lifetime incremental cost-effectiveness ratios, measured as cost per quality-adjusted year of life (QALY) gained, were calculated. Compared with PTCA, stenting increased procedural costs by $1148 and initial hospital costs by $1384 (both P<0.001). By 1-year, stenting led to fewer repeat revascularization procedures and reduced follow-up medical care costs by $1215, such that aggregate costs were similar for the PTCA and stent groups ($18 690 versus $18 859, P=0.75). The cost-effectiveness ratio for stenting versus PTCA was favorable at $11 237/QALY gained and remained <$20 000/QALY in sensitivity analyses. Compared with standard anticoagulation, abciximab increased initial procedural costs by $1122 (P<0.001). By facilitating accelerated hospital discharge, abciximab reduced length of stay by ≈0.6 days, offsetting most of the drug costs. These cost offsets were not maintained, however; aggregate 1-year costs for the abciximab group were $1244 greater than for standard therapy ($19 389 versus $18 145, P=0.02). Abciximab was reasonably cost-effective (cost-effectiveness ratio $21 305/QALY) only if nonsignificant differences in 1-year mortality (3.7% versus 4.3%, P=0.62) were incorporated in the analysis. Conclusions-Primary stenting is a highly cost-effective treatment for AMI. The cost-effectiveness of abciximab in this setting is uncertain and depends primarily on whether long-term survival is enhanced.