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Preventing Sudden Cardiac Death: Can We Afford the Benefit?
- Stephen G. Pauker, MD;
- N. A. Mark Estes, MD; and
- Deeb N. Salem, MD
- From Tufts-New England Medical Center and Tufts University School of Medicine; Boston, MA 02111.
Over the past 2 decades, we have made progress toward the Holy Grail of preventing sudden cardiac death. The implantable cardioverter defibrillator (ICD) is an effective but expensive therapy for primary and secondary prevention of this disorder (1, 2). Because health care resources are limited, when therapies are both effective and expensive, one must consider whether the benefits are worth the expense. A cost-effectiveness analysis answers that question by calculating the ratio of incremental cost to incremental effectiveness. Comparisons to other therapies are then possible. The lower the incremental cost-effectiveness ratio, the better the use of resources and the more cost-effective the therapy.
In this issue, analyzing the results of the Multicenter Automatic Defibrillator Implantation Trial (MADIT)-II (3), Al-Khatib and colleagues (4) conclude that ICDs have an acceptable incremental cost-effectiveness ratio in patients who have had a myocardial infarction (MI) at least 1 month before implantation and have an ejection fraction of 0.3 or less. To project beyond the 20-month follow-up reported in MADIT-II, the authors performed a cost-effectiveness analysis on patients in the Duke Cardiovascular Database who had cardiovascular profiles similar to those of MADIT-II participants (5). Al-Khatib and colleagues' results support the substantial body of evidence showing that ICDs have acceptable cost-effectiveness in patients with depressed ejection fraction after MI (6-12). One trial of ICD implantation 1 to 6 weeks after an MI in patients with an ejection fraction of 0.35 or less did not demonstrate a reduction in overall mortality (13), but the recently published Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) did demonstrate a survival benefit among patients with ischemic heart disease or dilated cardiomyopathy and an ejection fraction of 0.35 or less (14).
Al-Khatib and colleagues' analysis demonstrates the central importance of the ICD's ability to reduce the …
