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
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.
- Received October 23, 2017.
- Revision received December 29, 2017.
- Accepted January 3, 2018.
- 2018 American College of Cardiology Foundation