Author + information
- Received October 23, 2017
- Revision received December 29, 2017
- Accepted January 3, 2018
- Published online May 21, 2018.
- Kathryn Coyle, BSc Pharm, MSca,
- Doug Coyle, MA, MSc, PhDa,b,
- Isabelle Nault, MDc,
- Ratika Parkash, MDd,
- Jeffrey S. Healey, MDe,
- Christopher J. Gray, MDd,f,
- Martin J. Gardner, MDd,f,
- Laurence D. Sterns, MDf,
- Vidal Essebag, MD, PhDg,
- Tomasz Hruczkowski, MDh,
- Louis Blier, MDc,
- George A. Wells, PhDb,i,
- Anthony S.L. Tang, MDj,
- William G. Stevenson, MDk and
- John L. Sapp, MDd,∗ ()
- aHealth Economics Research Group, Institute of Environment, Health and Societies, Brunel University, London, United Kingdom
- bSchool of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- cDepartment of Medicine, Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Quebec, Canada
- dDepartment of Medicine, Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, Canada
- eDepartment of Medicine, Population Health Research Institute, Hamilton, Canada
- fDepartment of Medicine, Royal Jubilee Hospital, Victoria, Canada
- gDepartment of Medicine, McGill University Health Centre and Hôpital Sacre-Coeur de Montreal, Montreal, Canada
- hUniversity of Alberta, Edmonton, Canada
- iDepartment of Medicine, University of Ottawa Heart Institute, Ottawa, Canada
- jDepartment of Medicine, Western University, London, Canada
- kDepartment of Medicine, Vanderbilt University, Nashville, Tennessee
- ↵∗Address for correspondence:
Dr. John L. Sapp, Queen Elizabeth II Health Sciences Centre, Dalhousie University, Room 2501B, Halifax Infirmary, 1796 Summer Street, Halifax, Nova Scotia B3H 3A7, Canada.
Objectives This analysis uses the data from the randomized controlled trial to assess the cost effectiveness of catheter ablation (n = 132) versus escalated antiarrhythmic therapy (n = 127).
Background For survivors of myocardial infarction with implantable cardioverter-defibrillator shocks despite antiarrhythmic drugs, the VANISH (Ventricular Tachycardia Ablation Versus Escalated Antiarrhythmic Drug Therapy in Ischemic Heart Disease) trial demonstrated improved clinical outcomes with catheter ablation compared with more aggressive antiarrhythmic pharmacotherapy.
Methods Health care resource use and quality-of-life data were used to determine the cost effectiveness of catheter ablation. Published references were used to estimate costs (in 2015 Canadian dollars). The analysis was over 3 years, with a 5% discount rate. Adjustment was made for censoring and baseline utilities.
Results Ablation resulted in greater quality-adjusted life-years (QALYs) than escalated drug therapy did (1.63 vs. 1.49; difference: 0.14; 95% confidence interval [CI]: −0.20 to 0.46) and higher cost ($65,126 vs. $60,269; difference: $4,857; 95% CI: −$19,757 to $27,106); with an incremental cost per QALY gained for ablation versus escalated drug therapy of $34,057 primarily due to the initial costs of ablation, which were partially offset by the costs of subsequent ablations and adverse outcomes in the escalated drug therapy arm. For patients with amiodarone-refractory ventricular tachycardia, ablation dominated escalated drug therapy, with greater QALYs (1.48 vs. 1.26; difference: 0.22; 95% CI: −0.19 to 0.59) and lower costs ($67,614 vs. $68,383; difference: −$769; 95% CI: −$35,330 to $27,092). For those with sotalol-refractory ventricular tachycardia, ablation resulted in similar QALYs (1.90 vs. 1.90; difference: −0.00; 95% CI: −0.59 to 0.62) and higher costs ($60,455 vs. $45,033; difference: $15,422; 95% CI: −$10,968 to $48,555).
Conclusions For the total trial population, results are suggestive that ablation is cost effective compared with escalation of drug therapy. This result was only manifest for the subgroup of patients whose qualifying arrhythmia occurred despite amiodarone.
- antiarrhythmic drug therapy
- catheter ablation
- cost effectiveness
- implantable cardioverter-defibrillator
- ventricular tachycardia
Myocardial infarction (MI) and consequent scar can lead to ventricular tachycardia (VT), which is the leading cause of sudden cardiac death. The annual incidence of sudden cardiac death in the United States is estimated between 180,000 and 250,000 and in Canada between 20,300 and 28,000, with 40% of cases resulting from VT or ventricular fibrillation (1,2). VT occurs when electrical activation of the myocardium is interrupted by re-entrant impulses through heterogeneous infarction scar.
First-line treatment of VT secondary to an MI includes the insertion of an implantable cardioverter-defibrillator (ICD) (3). Antiarrhythmic drug (AAD) therapy is often utilized as an initial therapy to suppress recurrences, but may not be completely effective. The VANISH trial compared escalation of AAD therapy to catheter ablation: 2 common strategies for the treatment of VT, which occurs in this population despite first-line AAD therapy (4). The VANISH trial investigators found a significantly lower rate of the primary composite endpoint of cardiac death, appropriate ICD shock and VT storm in patients undergoing catheter ablation as compared with escalated antiarrhythmic therapy. In a subgroup analysis, the superiority of catheter ablation over escalated drug therapy with respect to the primary endpoint was marked in those patients who were receiving amiodarone at baseline (amiodarone refractory), but not in those who were not (sotalol refractory).
Given the significant upfront costs of catheter ablation and the scarce availability of health care resources, recommendations regarding the place of catheter ablation in therapy should consider not only the effectiveness of treatment, but also its cost effectiveness. In addition to its upfront costs, catheter ablation is also associated with a number of procedural adverse events, which may affect both the costs of treatment and the quality of life of patients. Treatment with AADs is also not without cost and quality-of-life implications due to their high incidence of adverse effects.
The objective of this analysis is to compare the long-term cost effectiveness of catheter ablation versus escalated antiarrhythmic therapy in patients who experience VT despite implantation of an ICD and use of antiarrhythmic therapy post-MI.
The VANISH trial was a randomized multicenter clinical study with blinding of endpoint adjudicators which compared the efficacy of catheter ablation (ablation therapy; n = 132) versus escalation of AAD therapy (escalated therapy; n = 127) in patients who had previously suffered an MI, had an implanted ICD, and experienced VT despite administration of an AAD. Detailed results of the trial have been reported previously (4). The following is a brief summary. Patient randomization was stratified by the presence or absence of amiodarone therapy at baseline. In those patients receiving an AAD other than amiodarone (sotalol in all but 1 patient) and randomized to escalated therapy, amiodarone therapy was initiated with a loading dose over a 6-week period and then maintained at 200 mg/day. In those patients receiving amiodarone therapy at baseline and randomized to escalated therapy, if the dose was <300 mg of amiodarone, patients were given a loading dose over 3 weeks followed by a maintenance dose of 300 mg/day and if the dose was 300 mg/day or more, an alternative antiarrhythmic (mexiletine) was added to amiodarone. In the ablation group, the procedure was completed within 14 days of randomization. Patients were followed for a mean of 27.9 ± 17.1 months (further details provided in Online Table 1).
In the overall group, there was a significant reduction in the occurrence of the primary outcome, a composite of death, VT storm, and appropriate ICD shock after a 30-day treatment period in patients randomized to catheter ablation versus escalated drug therapy. In subgroup analysis, there was no significant difference in the primary endpoint in the sotalol-refractory subgroup, whereas in the amiodarone-refractory subgroup catheter ablation resulted in a significantly greater improvement in the primary endpoint as compared with escalated drug therapy. Treatment-attributed adverse events were more common with escalated drug therapy, with 51 events as compared with 22 events in the ablation group. Hepatic dysfunction, ataxia, tremor, and treatment change due to drug adverse effects were more common in the escalated therapy group, whereas major bleeding, vascular injury, and cardiac perforation, although rare, were more common with ablation therapy.
Form of analysis
We conducted a trial-based analysis using data from the VANISH trial to compare the cost effectiveness of catheter ablation versus escalated drug therapy. Analysis was stratified by whether the qualifying arrhythmia was amiodarone refractory (n = 85 receiving catheter ablation and n = 84 receiving escalated drug therapy) or sotalol refractory (n = 47 receiving catheter ablation and n = 43 receiving escalated therapy) given the differing clinical results in these subgroups. The timeframe for the analysis was 36 months, as there was no difference in survival between the 2 treatments and the impact of the ablation intervention was likely to have dissipated by this timeframe. When results are likely to vary by patient stratifications, economic evaluations ignoring such heterogeneity will be biased (5). Thus, less biased results for the overall patient population are estimated by weighted analysis combining the results of the 2 subgroups. In addition, results are presented for the 2 subgroups. Results are presented in the form of a cost utility analysis with outcomes expressed as quality-adjusted life-years (QALYs). Analysis identified those components of total costs, which varied by treatment. Analysis was conducted from the perspective of the health care system, with costs and effects discounted at rate of 5% per annum, as recommended within Canadian Guidelines (6). Sensitivity analysis was conducted with 0%, 1.5%, and 3% discount rates.
Resource utilization and costs
Information regarding resource use was collected from patients at all scheduled and unscheduled visits. Schedule visits occurred at baseline, 3 months, 6 months, and every 6 months thereafter. Collected data included the number of family and specialist physician visits, medication changes, event hospitalizations and emergency room visits, ICD revisions and ablation procedures, and associated hospitalizations. Canadian unit costs were applied to resource use to calculate patient costs at each of the scheduled follow-up time points.
Medication costs were sourced from the Ontario Drug Benefit Formulary, physician fees from the Ontario Schedule of Physician Fees, and the costs of hospitalizations and procedures from the Ontario Case Costing Initiative (7–9). The cost of emergency room visits was as reported by the Canadian Institute of Health Information (10). A dispensing fee of $8.83 and an 8% markup was included for all medications (11,12). All costs were inflated to the year 2015 (13) (see Online Table 2 for unit costs).
The quality of life of patients was assessed at baseline, 3 months, and at annual scheduled visits thereafter, through completion of the EQ-5D. The EQ-5D is a well-established general health questionnaire whose scores were converted into utility measures using a validated conversion algorithm based on UK weights (14). Death is reflected as a utility score of 0, whereas perfect health results in a utility score of 1. QALYs were estimated from the utility scores using the area-under-the-curve method, which assumes linear interpolation between data points. Adjustment for differences in baseline utility was conducted using linear regression.
At both scheduled and unscheduled visits, patients reported resource use since their previous visit. Consequently, intervening data regarding costs was complete up until the point at which patients were censored (withdrawn, lost to follow-up, or due to end-of-trial follow-up). Similarly, with respect to QALYs, the estimation method assumes linear interpolation between time points, and therefore data were complete up to the point at which patients were censored. Inverse probability weighting was used to adjust for missing data from the point of censoring (15). For further details, see the Online Appendix and Online Tables 3 and 4.
A combination of probabilistic sensitivity analysis and bootstrap resampling was used to assess uncertainty around the estimate of costs and outcomes (16). Given the Bayesian approach in assessing uncertainty propagation, uncertainty around results are presented in the form of confidence intervals (CIs). The uncertainty of parameter estimates for the costs of hospital bed days, procedures, ICD revisions, and emergency room visits were represented by gamma distributions. Physician fees and medication costs were considered fixed. Uncertainty in all other parameters was captured within the bootstrap resampling. The results are presented in a cost-effectiveness acceptability curve, which displays the probability that a treatment option is cost effective for different threshold values of a QALY.
Data were subject to right censoring due to curtailment of data collection. As a result, in approximately half of patients cost data were complete for the full 36-month follow-up period and utility data were complete in approximately 40% of patients. Censoring was not differential by treatment randomization or by drug subgroup (see the Online Appendix).
For the total trial population, ablation resulted in greater QALYs than escalated therapy (1.63 vs. 1.49; difference: 0.14; 95% CI: −0.20 to 0.46) and a higher cost ($65,126 vs. $60,269; difference: $4,857; 95% CI: −$19,757 to $27,106) (see Table 1). The ablation arm incurred the additional cost for the initial procedure of $12,371 on average per person. The cost of the initial hospitalization was also higher in the ablation group as compared with escalated therapy ($8,271 vs. $3,068; difference: $5,204; 95% CI: $3,216 to $8,540). There were, however, lower costs per person for subsequent ablations within the ablation arm compared with escalated therapy ($4,128 vs. $13,210; difference: −$9,082; 95% CI: −$19,578 to −$3,725) and for cardiovascular events ($26,668 vs. $30,164; difference: −$3,496; 95% CI: −$21,715 to $12,441). All other costs, including those of physician visits, laboratory and diagnostic tests, ICD revisions, and cardiovascular medications, were comparable between the 2 groups (see Online Tables 5 and 6 for EQ-5D scores and frequency of subsequent catheter ablations).
Within the VANISH trial, patient randomization was stratified based on whether the patients’ index arrhythmia was refractory to amiodarone or sotalol and a pre-specified subgroup analysis for these groups was conducted. To provide further insight into the cost-effectiveness results, we also conducted subgroup analysis based these subgroups.
In the amiodarone-refractory subgroup, catheter ablation resulted in greater QALYs, 1.48, as compared with escalation of AAD therapy, which produced 1.26 QALYs (mean difference of 0.22; 95% CI: −0.20 to 0.59). Conversely, in the sotalol-refractory subgroup, the QALYs with each intervention were equivalent, with both interventions resulting in a mean of 1.90 QALYs (mean difference of −0.00; 95% CI: −0.59 to 0.62).
With respect to the mean overall cost per patient over 3 years for those receiving amiodarone at baseline, the costs within the ablation arm of the trial were lower, at $67,614, as compared with the escalated-therapy arm, at $68,383 (mean difference of −$769; 95% CI: −$35,330 to $27,092). The opposite was seen in those not receiving amiodarone at baseline, with the ablation arm having higher costs of $60,455 and lower costs with escalated therapy of $45,033 (mean difference of $15,422; 95% CI: −$10,968 to $48,555).
The differences between the overall costs in the 2 subgroups stem primarily from differences in the costs of the baseline hospitalizations, catheter ablations, and cardiovascular events. In both subgroups, the cost of baseline hospitalizations was higher in the ablation arm as compared with the escalated-therapy arm ($9,663 vs. $3,248 for amiodarone refractory [difference: $6,415; 95% CI: $3,911 to $10,892] and $5,657 vs. $2,729 in sotalol refractory [difference: $2,929; 95% CI: $795 to $5,847]). The ablation arm also incurred the additional cost of the initial ablation procedure, which was a mean of $12,528 per person (95% CI: $5,962 to $32,885) for amiodarone refractory and $12,076 (95% CI: $5,859 to $30,157) for sotalol refractory. There were, however, differences between the 2 subgroups in the cost of subsequent ablations as a result of crossover within the escalated therapy arm or the need for additional ablations in the ablation arm. In amiodarone-refractory patients, the cost of subsequent ablations in the ablation arm was much lower than with the escalated therapy arm ($3,381 [95% CI: $1,511 to $9,932] vs. $17,205 [95% CI: $8,441 to $35,056]). On the other hand, the cost of subsequent ablations for sotalol-refractory patients was comparable between the 2 groups ($5,529 in ablation arm [95% CI: $2,376 to $15,937] vs. $5,707 with escalated therapy [95% CI: $2,451 to $18,448]). There were more crossover ablations in the escalated therapy arm in amiodarone-refractory patients than in sotalol refractory patients (0.61/patient vs. 0.35/patient). The number of repeat ablation procedures in the ablation therapy arm was lower in amiodarone-refractory patients than in sotalol-refractory patients (0.16/patient vs. 0.31/patient).
Additionally, the cost of cardiovascular events was lower in the ablation arm at $27,500 (95% CI: $19,882 to $85,826) than in the escalated therapy arm at $34,152 (95% CI: $22,788 to $75,198) in amiodarone-refractory patients. The opposite was true for the cost of cardiovascular events in sotalol-refractory patients, where the costs were higher in the ablation arm than with escalated therapy ($25,107 [95% CI: $10,749 to $58,445] vs. $22,676 [95% CI: $12,627 to $50,916]).
All other costs, including those for diagnostic and lab tests, physician visits, ICD revisions, and medications, were not substantially different between the ablation and escalated therapy groups in both amiodarone-refractory patients and sotalol-refractory patients.
With respect to the cost effectiveness of ablation versus escalated drug therapy, in the total population the incremental cost per QALY is $34,057. In considering the subgroup analysis, in amiodarone-refractory patients, ablation dominated escalation of AAD, as it resulted in greater QALYs (1.48 vs. 1.26, an increase of 0.22 [95% CI: −0.19 to 0.59]) and lower costs ($67,614 vs. $68,383, a difference of −$769 [95% CI: −$35,330 to $27,092]).
In sotalol-refractory patients there was no difference between the arms with respect to the gains in QALYs (1.90 in both groups, a difference of 0.00 [95% CI: −0.59 to 0.62]); however, the catheter ablation arm incurred higher costs over the 3 years of follow-up ($60,455 vs. $45,033, a difference of $15,422 [95% CI: −$10,968 to $48,555]). Results were robust to alternative discount rates ranging from 0% to 3% (see Online Table 7).
The results of the probabilistic sensitivity analysis and bootstrap analysis are presented graphically in Figure 1. At a willingness-to-pay threshold of $50,000 per QALY, there is a 57% probability that ablation is more cost effective based on the analysis of the total trial population. For amiodarone-refractory patients, there is a 75% probability that ablation is more cost effective than escalated therapy, whereas in sotalol-refractory patients there is a 24% probability that ablation is the more cost-effective strategy, at the same threshold. At a willingness-to-pay threshold of $100,000 per QALY, there is a 68% probability that ablation is more cost effective for the total trial population, while the probabilities for amiodarone- or sotalol-refractory patients were 82% and 33%, respectively (further details in Online Tables 8 and 9).
The cost-effectiveness analysis compared catheter ablation versus escalation of antiarrhythmic therapy in patients whose index VT occurred while receiving antiarrhythmic therapy post–MI and implant of an ICD. Catheter ablation was found to be cost effective at willingness-to-pay thresholds of $50,000 and $100,000 per QALY, with an incremental cost-effectiveness ratio of $34,057 per QALY. However, there is substantial uncertainty with respect to this finding and the probability that catheter ablation is cost effective given a threshold of $50,000 is 57%; the corollary, of course, is that the probability that escalated therapy is cost effective is 43%. At $100,000 per QALY the probability that catheter ablation is cost effective is 68%.
Economic evaluation incorporating consideration of heterogeneity often leads to less uncertain findings. Subgroup analysis, based on which AAD was in use during the index event, found that for patients with amiodarone-refractory VT, catheter ablation was more cost effective than escalated therapy, as it was both less costly and produced greater QALYs. The probability that catheter ablation is cost effective in this subgroup is 75% (only a 25% probability that escalated therapy is cost effective). In patients with sotalol-refractory VT, there was no difference between the 2 interventions with respect to the QALYs gained; however, ablation therapy was costlier, leading to the probability of catheter ablation being cost effective of only 24%. In both subgroups, those in the ablation group incurred the added cost of the ablation procedure and hospitalization; however, in those receiving amiodarone at baseline, these upfront costs were balanced in the escalated-therapy group by higher costs for ablation procedures over the 3-year follow-up period and higher costs of cardiovascular and adverse events.
A previous cost-effectiveness modeling study comparing catheter ablation versus amiodarone in patients post-MI with VT who were not receiving antiarrhythmic therapy found that ablation was costlier than amiodarone, but also produced greater QALYs (17). The resulting cost-effectiveness ratio for ablation versus antiarrhythmic therapy was US$20,923 per QALY. This analysis differs from the current study in a number of ways. The patient population in the current study was experiencing recurrent VT despite antiarrhythmic therapy, whereas those in the previous study were not receiving antiarrhythmic therapy at baseline. The results of the current analysis are based on 3 years of follow-up, whereas the previous analysis was based on 6 months of clinical trial follow-up, with the longer-term impacts over 5 years requiring a number of modeling assumptions. Finally, in the previous study, utilities were derived from clinicians, unlike in the current study, in which they were derived from the patients within the trial. Studies have shown that elicitation of utilities from different groups can result in differences in health state valuation (18).
A particular strength of the current study is that the duration of follow-up allowed more precise estimation of the longer-term impact of the interventions on health care costs and QALYs. The duration of follow-up may significantly impact the estimated comparative cost effectiveness of the interventions. If there are frequent ICD shocks due to lack of control of VT, this may lead to greater impairment of patient quality of life and potentially to early and more frequent replacement of ICDs, thereby increasing costs. The results of the trial did not find evidence of a differential need for replacement of ICDs between ablation and escalated drug therapy. Additionally, the duration of follow-up allows for estimation of longer-term durability of catheter ablation allowing incorporation of costs of retreating patients. The need for further ablation procedures due to drug inefficacy, side effects, or intolerance, or to progression of the underlying arrhythmic substrate, may be a concern over the long term. The number of ablations subsequent to the index procedure within the ablation arm was low, suggesting effective suppression with a single procedure in the majority of patients.
An additional strength of the study is the assessment of quality of life with a validated instrument by patients at multiple time points throughout the follow-up time period. This provides a true reflection of the patients’ perception of the balance of the benefits and the drawbacks of the 2 treatment options.
Another advantage of this study was the ability to conduct analysis for 2 patient strata—those receiving amiodarone at baseline and those not receiving amiodarone at baseline. Stratified cost-effectiveness analysis is an appropriate analytical technique, as it facilitates decision makers making differential funding decisions within a patient population (19). Thus, it provides both a more precise estimate of cost effectiveness for the overall population and richer information to decision makers.
The main limitation of the current analysis was that, as with many long-term studies, a number of patients were censored before the 3-year time frame of the analysis. However, few patients were lost to follow-up, and the censoring did not differ significantly between the 2 treatments or by subgroup. There remains the possibility, however, that 3 years of follow-up may not capture the difference in adverse events between the 2 treatment interventions. In particular, it may miss progression of the disease within the ablation group and may miss adverse drug effects, which tend to occur relatively late among patients treated with amiodarone.
Basing the analysis on a 3-year time horizon, rather than a lifetime horizon, may be viewed as a limitation; however, the decision was based on a number of considerations. First, there was no evidence for a difference in overall survival between the treatment groups, and therefore extrapolating over a lifetime would have little impact on the cost-effectiveness estimate, but would require additional assumptions. The limited follow-up duration within the trial makes it challenging to estimate the difference in effectiveness over a lifetime, particularly, as with longer-term follow-up, there is greater potential for those in the escalated drug therapy to cross over to catheter ablation, leading to dilution of the comparative effectiveness of treatments.
Caution should be exercised in the interpretation of both the cost and quality-of-life estimates, particularly with respect to the subgroups analysis, given that these groups had limited patient numbers. This is particularly true for the group with sotalol-refractory VT in which there were 47 patients in the ablation arm and 43 in the escalated-therapy arm. Additionally, as quality of life was evaluated via the EQ-5D at intervals throughout the trial corresponding to clinic visits, the impact of acute events such as ventricular arrhythmias or shocks on patients’ well-being may not be fully captured. However, given the transient nature of such events, this would be unlikely to have a significant quantitative impact on results, and thus unlikely to change the study conclusions.
The ability to generalize economic evaluations from one jurisdiction to another is limited by both clinical and cost concerns. We do think that the clinical results of the trial are generalizable beyond Canada. Centers outside Canada did participate, but the large majority of patients were enrolled within Canada. The clinical results are likely to be generalizable to patient care where advanced arrhythmia care is available to patients, including appropriate therapy for ischemic heart disease, defibrillator implantation, and access to arrhythmia specialists. Catheter ablation procedures performed in Canada are similar in nature and indication to those of other countries with advanced health care. The cost estimates may vary in different health care models. In those jurisdictions where the relative costs of resources are likely to be similar results may be transferable, given the results of our scenario analysis.
Overall, our results suggest that catheter ablation is cost effective based on a willingness to pay of $50,000 per QALY; however, there is considerable uncertainty regarding this conclusion. Subgroup analysis produced varied results, but greater certainty. In those patients receiving amiodarone at baseline, ablation was more effective and less costly, whereas in those not receiving amiodarone at baseline there was no difference in QALYs between treatments, but ablation was costlier.
COMPETENCY IN MEDICAL KNOWLEDGE: For patients with prior MI, an ICD, and VT occurring despite AAD therapy, catheter ablation offers better protection from recurrent arrhythmias than escalated AAD therapy does, at a cost that may be considered acceptable. For patients with amiodarone-refractory VT, catheter ablation provides better outcomes at lower cost. For patients with sotalol-refractory VT, catheter ablation and escalated AAD therapy provides similar outcomes but ablation is costlier.
TRANSLATIONAL OUTLOOK: This study provides estimates of the relative cost effectiveness of catheter ablation compared with escalated AAD therapy for patients with drug-refractory VT. Further studies will be required to establish the comparative efficacy and cost effectiveness of first-line AAD therapy.
Drs. Nault, Parkash, Healey, Gray, Gardner, Sterns, Essebag, Hruczkowski, Blier, Wells, Tang, and Sapp are members of the Cardiac Arrhythmia Network of Canada. The VANISH trial was funded by the Canadian Institutes of Health Research, with supplemental funding from St. Jude Medical and Biosense Webster. Dr. Essebag was supported by a Clinical Research Scholar Award from the Fonds de recherche de Québec-Santé. Dr. Nault has received consulting honoraria from Biosense Webster, Bayer, Servier, BMS-Pfizer, Boehringer Ingelheim, and Medtronic. Dr. Parkash has received research funding from St. Jude Medical. Dr. Healey has received research funding from St. Jude Medical, Medtronic, and Abbott Vascular. Dr. Essebag has received honoraria from Biosense Webster, St. Jude Medical, Medtronic, and Boston Scientific. Dr. Stevenson has received honoraria from St. Jude Medical and Boston Scientific; is co-holder of a patent for needle ablation; and has a spouse who has received modest research funding from St. Jude Medical. Dr. Sapp has received research funding from St. Jude Medical/Abbott and Biosense Webster; modest lecture fees from St. Jude Medical; and honoraria from Abbott. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
All authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.
- Abbreviations and Acronyms
- antiarrhythmic drug
- confidence interval
- implantable cardioverter-defibrillator
- myocardial infarction
- quality-adjusted life-year
- ventricular tachycardia
- Received October 23, 2017.
- Revision received December 29, 2017.
- Accepted January 3, 2018.
- 2018 American College of Cardiology Foundation
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