J Am Coll Cardiol, doi:10.1016/j.jacc.2006.02.051 (Published online 7
June 2006)
© 2006 by the American College of Cardiology
Foundation
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CLINICAL RESEARCH: HEART
RHYTHM DISORDERS
Cost-Effectiveness of a
Microvolt T-Wave Alternans Screening Strategy for Implantable
Cardioverter-Defibrillator Placement in the MADIT-II–Eligible Population
,*, 
, 
, ,
* VA Center for Practice Management and Outcomes
Research, Ann Arbor, Michigan
University of Michigan, Ann Arbor,
Michigan
Weill Medical Center, Cornell University, New York, New York
The Lindner Clinical Trial Center at
the Christ Hospital and the Ohio Heart and Vascular Center, Cincinnati, Ohio
|| Columbia University Medical Center, New York, New York
Manuscript received November 2, 2005; revised manuscript received
January 31, 2006, accepted February 7, 2006.
* Reprint requests and correspondence:
Dr. Paul S. Chan, VA Ann Arbor Healthcare System, Cardiology (111-A), 2215
Fuller Road, Ann Arbor, Michigan 48105 (Email: paulchan@umich.edu
).
OBJECTIVES: This study was designed to compare
the cost-effectiveness of implantable cardioverter-defibrillator
(ICD) placement with and without risk stratification with microvolt
T-wave alternans (MTWA) testing in the MADIT-II (Second Multicenter
Automatic Defibrillator Implantation Trial) eligible population.
BACKGROUND: Implantable cardioverter-defibrillators have been shown to
prevent mortality in the MADIT-II population. Microvolt T-wave
alternans testing has been shown to be effective in risk stratifying
MADIT-II–eligible patients.
METHODS: On the basis of published data, cost-effectiveness of three
therapeutic strategies in MADIT-II–eligible patients was assessed
using a Markov model: 1) ICD placement in all; 2) ICD placement in
patients testing MTWA non-negative;, and 3) medical management. Outcomes
of expected cost, quality-adjusted life-years (QALYs), and
incremental cost-effectiveness were determined for patient lifetime.
RESULTS: Under base-case assumptions, providing ICDs only to those who
test MTWA non-negative produced a gain of 1.14 QALYs at an incremental
cost of $55,700 when compared to medical therapy, resulting in
an incremental cost-effectiveness ratio (ICER) of $48,700/QALY. When
compared with a MTWA risk-stratification strategy, placing ICDs in
all patients resulted in an ICER of $88,700/QALY. Most (83%) of the
potential benefit was achieved by implanting ICDs in the 67% of
patients who tested MTWA non-negative. Results were most sensitive
to the effectiveness of MTWA as a risk-stratification tool, MTWA
negative screen rate, cost and efficacy of ICD therapy, and patient
risk for arrhythmic death.
CONCLUSIONS: Risk stratification with MTWA testing in MADIT-II–eligible
patients improves the cost-effectiveness of ICDs. Implanting defibrillators
in all MADIT-II–eligible patients, however, is not cost-effective,
with one-third of patients deriving little additional benefit at
great expense.
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