Burden of oral anticoagulation in embolic stroke of undetermined source without atrial fibrillation
Autor: | Vincent Thijs, Stelios I Tsintzos, Simon Eggington, Eleni Ismyrloglou, Georgios Tsivgoulis, Marta Egea, Rashmi Joglekar, Matthew R. Reynolds, Shufeng Liu, Noreli Franco, Sarah C Rosemas, Bonnie de Brouwer, Julie Lyon, Paul D. Ziegler, Marianne Huynh, Klaus K. Witte |
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Rok vydání: | 2021 |
Předmět: |
lcsh:Diseases of the circulatory (Cardiovascular) system
medicine.medical_specialty Time Factors Cost-Benefit Analysis Population Administration Oral Hemorrhage Pharmacy Risk Assessment Drug Costs Dabigatran Rivaroxaban Recurrence Risk Factors Secondary Prevention medicine Humans education Ischemic Stroke Retrospective Studies Angiology Clinical Trials as Topic Embolic Stroke Aspirin education.field_of_study business.industry Anticoagulants Atrial fibrillation medicine.disease Cardiac surgery Models Economic Treatment Outcome lcsh:RC666-701 Emergency medicine Cardiology and Cardiovascular Medicine business Research Article medicine.drug |
Zdroj: | BMC Cardiovascular Disorders BMC Cardiovascular Disorders, Vol 21, Iss 1, Pp 1-9 (2021) |
ISSN: | 1471-2261 |
Popis: | Objective Prevention of recurrent stroke in patients with embolic stroke of undetermined source (ESUS) is challenging. The advent of safer anticoagulation in the form of direct oral anticoagulants (DOACs) has prompted exploration of prophylactic anticoagulation for all ESUS patients, rather than anticoagulating just those with documented atrial fibrillation (AF). However, recent trials have failed to demonstrate a clinical benefit, while observing increased bleeding. We modeled the economic impact of anticoagulating ESUS patients without documented AF across multiple geographies. Methods CRYSTAL-AF trial data were used to assess ischaemic stroke event rates in ESUS patients confirmed AF-free after long-term monitoring. Anticipated bleeding event rates (including both minor and major bleeds) with aspirin, dabigatran 150 mg, and rivaroxaban 20 mg were sourced from published meta-analyses, whilst a 30% ischaemic stroke reduction for both DOACs was assumed. Cost data for clinical events and pharmaceuticals were collected from the local payer perspective. Results Compared with aspirin, dabigatran and rivaroxaban resulted in 17.9 and 29.9 additional bleeding events per 100 patients over a patient’s lifetime, respectively. Despite incorporating into our model the proposed 30% reduction in ischaemic stroke risk, both DOACs were cost-additive over patient lifetime, as the costs of bleeding events and pharmaceuticals outweighed cost savings associated with the reduction in ischaemic strokes. DOACs added £5953–£7018 per patient (UK), €6683–€7368 (Netherlands), €4933–€9378 (Spain), AUD$5353–6539 (Australia) and $26,768–$32,259 (US) of payer cost depending on the agent prescribed. Additionally, in the U.S. patient pharmacy co-payments ranged from $2468–$12,844 depending on agent and patient plan. In all settings, cost-savings could not be demonstrated even when the modelling assumed 100% protection from recurrent ischaemic strokes, due to the very low underlying risk of recurrent ischaemic stroke in this population (1.27 per 100 patient-years). Conclusions Anticoagulation of non-AF patients may cause excess bleeds and add substantial costs for uncertain benefits, suggesting a personalised approach to anticoagulation in ESUS patients. |
Databáze: | OpenAIRE |
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