In the Treat Angina with Aggrastat and Determine Cost of Therapy with
an Invasive or Conservative Strategy (TACTICS)–Thrombolysis in Myocardial
Infarction (TIMI) 18 trial, patients with either unstable angina or non–ST-segment
elevation myocardial infarction (UA/NSTEMI) treated with the platelet glycoprotein
(Gp IIb/IIIa) inhibitor tirofiban had a significantly reduced rate of major
cardiac events at 6 months with an early invasive vs a conservative strategy.
To examine total 6-month costs and long-term cost-effectiveness of an
invasive vs a conservative strategy.
Randomized controlled trial including a priori economic end points.
Hospitalization for UA/NSTEMI with 6-month follow-up period.
A total of 2220 patients with UA/NSTEMI; economic data from 1722 patients
at US–non-VA hospitals.
Early invasive strategy with routine catheterization and revascularization
as appropriate vs a conservative strategy with catheterization performed only
for recurrent ischemia or a positive stress test.
Main Outcome Measure
Total 6-month costs and incremental cost-effectiveness ratio.
The average initial hospitalization costs among those in the invasive
strategy group were $15714 vs $14047 among those in the conservative stategy
group, a difference of $1667 (95% confidence interval [CI], $387-3091). The
in-hospital costs were offset significantly at the 6-month follow-up, with
an average cost in the invasive group of $6098 vs $7180 in the conservative
group, a difference of $1082 (95% CI, −$2051 to $76). The average total
costs at 6 months, including productivity costs, for the invasive group was
$21 813 vs $21 227 for the conservative group, a $586 difference
(95% CI, −$1087 to $2486). The average 6-month costs excluding productivity
costs in the invasive group was $19 780 vs $19 111 in the conservative
group, a difference of $670, 95% CI; (−$1035 to $2321). Estimated cost
per year of life gained for the invasive strategy, based on projected life
expectancy, was $12739 for the base case, and ranged from $8371 to $25769,
based on model assumptions.
In patients with UA/NSTEMI treated with the Gp IIb/IIIa inhibitor tirofiban,
the clinical benefit of an early invasive strategy was achieved with a small
increase in cost, yielding favorable projected estimates of cost per year
of life gained. These results support the broader use of an early invasive
strategy in these patients.