Abstract only
Sudden cardiac death (SCD) is a rare but frightening event among young athletes. The Italian experience demonstrates a reduction in athlete SCD by screening with history, physical, and ...12-lead electrocardiogram (ECG). American guideline statements have not recommended ECG for screening athletes due to perceptions of high cost and unclear effectiveness. We sought to model the cost-effectiveness (CE) of history and physical (H&P), ECG plus H&P, and no screening in US high school and college competitive athletes. A decision analysis model was used. Risks, prevalence, and test characteristics were derived from the medical literature. Costs were derived from publicly available datasets. Markov processes were used to simulate the natural histories of screened athletes. One-way sensitivity analyses and Monte Carlo simulation of all variables in the estimated ranges were performed. A societal perspective was used. Screening with an ECG plus H&P has lower overall costs and better outcomes than use of H&P alone. Compared with no screening, H&P saves 0.57 life years (LY) per 1000 athletes screened at an incremental cost of $111 per athlete, yielding a CE ratio of $195,600 per LY saved (simulation based 95% CI $116,000–514,000). ECG plus H&P when compared to no screening saves 2.7 LY per 1000 athletes at an incremental cost of $199 per athlete, for a CE ratio of $74,100 per LY saved (95% CI $46,000–158,000). Probabilistic sensitivity analysis shows that ECG plus H&P is the preferred strategy over H&P in terms of cost-effectiveness in 99.5% of simulations. ECG plus H&P is cost-effective below a threshold value of $100,000 per LY saved in 89% of simulations, while H&P is cost-effective in 1% of simulations. If the reduction in SCD risk per screening-identified, at-risk athlete is below 33%, or if more than 12% of screens are false positive, screening with ECG plus H&P is no longer cost effective. ECG plus H&P is superior to H&P for screening young athletes in our cost-effectiveness model. The incremental cost of adding an ECG, including screening, secondary testing, and subsequent treatment is under $100 per athlete screened. These data should inform the ongoing debate concerning pre-participation screening of US student-athletes.
Preventing tomorrow's sudden cardiac death today Sanders, Gillian D., PhD; Al-Khatib, Sana M., MD, MHS; Berliner, Elise, PhD ...
The American heart journal,
2007, Letnik:
153, Številka:
6
Journal Article
Recenzirano
Although current evidence supporting a more precise strategy for identifying patients at highest risk for sudden cardiac death (SCD) is sparse, strategies for translating existing and future evidence ...into clinical practice and policy are needed today. A great many unanswered questions exist. Examples include the following: At what level of risk for SCD should we pursue further testing or therapy? How should clinical strategies ethically and economically balance alternative outcomes? How can we best translate optimal strategies into clinical practice so as to prevent tomorrow's SCDs? On July 20 and 21, 2006, a group of individuals with expertise in clinical cardiovascular medicine, biostatistics, economics, and health policy was joined by government (Food and Drug Administration; Centers for Medicare and Medicaid Services; National Heart, Lung, and Blood Institute; Agency for Healthcare Research and Quality), professional societies (Heart Rhythm Society), and industry to discuss strategies for risk assessment and prevention of SCD. The meeting was organized by the Duke Center for the Prevention of Sudden Cardiac Death and the Duke Clinical Research Institute. This article, the second of 2 documents, summarizes the policy discussions of that meeting, discusses an analytic framework for evaluating the risks and benefits associated with SCD prevention and risk stratification, and addresses the translation of SCD risk assessment strategies into practice and policy.
Background. To characterize the association of antiretroviral drug combinations on risk of cardiovascular events. Methods. Certain antiretroviral medications for human immunodeficiency virus (HIV) ...have been implicated in increasing risk of cardiovascular disease. However, antiretroviral drugs are typically prescribed in combination. We characterized the association of current exposure to antiretroviral drug combinations on risk of cardiovascular events including myocardial infarction, stroke, percutaneous coronary intervention, and coronary artery bypass surgery. We used the Veterans Health Administration Clinical Case Registry to analyze data from 24 510 patients infected with HIV from January 1996 through December 2009. We assessed the association of current exposure to 15 antiretroviral drugs and 23 prespecified combinations of agents on the risk of cardiovascular event by using marginal structural models and Cox models extended to accommodate time-dependent variables. Results. Over 164 059 person-years of follow-up, 934 patients had a cardiovascular event. Current exposure to abacavir, efavirenz, lamivudine, and zidovudine was significantly associated with increased risk of cardiovascular event, with odds ratios ranging from 1.40 to 1.53. Five combinations were significantly associated with increased risk of cardiovascular event, all of which involved lamivudine. One of these—efavirenz, lamivudine, and zidovudine—was the second most commonly used combination and was associated with a risk of cardiovascular event that is 1.60 times that of patients not currently exposed to the combination (odds ratio = 1.60, 95% confidence interval, 1.25–2.04). Conclusions. In the VA cohort, exposure to both individual drugs and drug combinations was associated with modestly increased risk of a cardiovascular event.
Do Patients Prefer Physiologic Pacing? Hlatky, Mark A; Mason, Jay W
The New England journal of medicine,
04/1998, Letnik:
338, Številka:
16
Journal Article
Recenzirano
Cardiac pacemakers have become increasingly sophisticated during their half-century of clinical use. Each new component has been designed to simulate normal physiology more precisely. Is such ...complexity necessary? In this issue of the
Journal,
Lamas and colleagues
1
report the results of the Pacemaker Selection in the Elderly (PASE) trial, a comparison of sophisticated dual-chamber pacing with less complex ventricular pacing in patients with bradycardia. The investigators conclude that dual-chamber pacing improved the quality of life, but the benefit was seen only in the subgroup with sinus-node dysfunction.
On the surface, it seems obvious that dual-chamber pacing would be superior to . . .
Diagnostic evaluation practices for suspected coronary artery disease (CAD) may vary between countries. Our objective was to compare a CT-derived fractional flow reserve (FFR
) diagnostic strategy ...with usual care in patients with planned invasive coronary angiography (ICA) enrolled in the PLATFORM (Prospective Longitudinal Trial of FFR
: Outcome and Resource Impacts) study at German sites.
Patients were divided into two consecutive observational cohorts, receiving either usual care or CT angiography (CTA)/FFR
. The primary endpoint was the percentage of patients planned for ICA, with no obstructive CAD on ICA within 90 days. Secondary endpoints included death, myocardial infarction, unstable angina, hospitalisation leading to unplanned revascularisation, cumulative radiation exposure, estimated medical costs and quality of life (QOL) at 1 year.
116 patients were included. The primary endpoint occurred in 4 of the 52 patients (7.7%) in the CTA/FFR
group and in 55 of the 64 patients (85.9%) in the usual care group (risk difference 78.2%, 95% CI 67.1% to 89.4%, p<0.001). ICA was cancelled in 40 of the 52 patients (77%) who underwent CTA/FFR
. Clinical event rates were low overall. The mean radiation exposure was lower in the FFR
versus the usual care group (7.28 vs 9.80 mSv, p<0.001). Mean estimated medical costs were €4217 (CTA/FFR
) versus €6894 (usual care), p<0.001. Improvement in QOL (EQ-5D score) was greater in the FFR
(+0.09 units) versus the usual care cohort (+0.03 units), p=0.04.
In patients with suspected CAD planned for ICA at German sites, initial CTA/FFR
compared with usual care was associated with a markedly reduced rate of ICA showing no obstructive CAD, lower cumulative radiation exposure and estimated costs and greater improvement in QOL.
PDF
