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European Heart Journal 1993 14(1):75-83;
Copyright © 1993 by the European Society of Cardiology.
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© 1993 The European Society of Cardiology

Cost effectiveness of thrombolytic treatment for myocardial infarction: comparison of anistreplase, alteplase and streptokinase in 270 patients treated within 4 hours

J. MACHECOURT*,, J. DUMOULIN§, J. CALOP*, L. FORONI*, M. P. TERISSE{dagger}, T. HENON{ddagger}, G. VANZETFO*, B. DENIS*, J. P. BASSAND{ddagger} and J. CASSAGNES{dagger}

*University Hospital Grenoble France
§CNRS Grenoble France
{dagger}University Hospital Clermont-Ferrand France
{dagger}University Hospital Besancon France

Received 4 March 1992; revised 12 June 1992; .

Correspondence: J. Machecourt, Clinique Cardiologique, CHU BP 217 X 38043, Grenoble, Cedex, France

Abstract

Two hundred and seventy patients, under 71 years of age and suffering from a less than 4 h infarction diagnosed according to clinical and electrocardiographic criteria, were included. two 90-patient groups were randomized and then treated with either anistreplase (30 mg iv over 5 min) or alteplase (10 mg bolus injection + 5000 IU heparin bolus injection, followed by 90 mg alteplase over 3 h), and compared with a consecutive control series of 90 patients treated with streptokinase (1.5 million U over 1 h). Intravenous heparin and aspirin (250 mg day–1) were then prescribed routinely. The three groups were comparable as regards age (55.2±10 years), male/female ratio (10.4 the site of the infarction (42% anterior, 55% inferior) and initial clinical seriousness (Killip I=90%, II=8%, III=2%). The patients were thombolysed in 17 community hospitals, and then referred to a university hospital with catheterization facilities. An efficacy score was determined, based on four parameters: two obtained from coronary angiography and left ventriculography performed on day 6±2 (N = 252) (asynergic score and patency of the infarct-related artery), one from Tl-tomography performed at rest (infarct size) and one from radionuclide angiography (global left ventricular ejection fraction) performed between day 15 and day 21 (N = 242). The score (range: 0–24 per patient) was 17.8±6.4 for alteplase, 17.7±6.0 for anistreplase and 18.1±6.0 for streptokinase respectively (NS). The real cost of the hospital phase, for each patient, was determined by adding up the cost of thrombolytic treatment (ranging from 1.7% of the total hospital cost for streptokinase to 16% for alteplase), other treatment and biological examinations (10% of the total cost), coronary angiography, followed in 35% of patients by angioplasty (21% of the overall cost) and hospitalization (ranging from 49% of the total cost for alteplase and anistreplase to 56% for streptokinase [NS] for an average 17-day hospitalization. Thus, the total cost of the hospital phase was 6460 ECU for alteplase, 6570 ECU for anistreplase and 6050 ECU for streptokinase (NS). The cost/efficacy ratio was 548 ECU for alteplase, 570 ECU for anistreplase and 405 ECU for streptokinase. Secondary mortality and re-infarction rates were very low (1.2% and 1.5% respectively) after 1 year following the treatment. However, ischaemia recurred in 23% of patients, requiring revascularization operations in 9% of them. Sixty-nine per cent of patients with professional occupations were able to resume these activities.

This study showed no difference in efficacy between the three thrombolytic agents for the three left ventricular parameters (left ventricular ejection fraction, asynergic score, necrotic mass) and for the patency of the infarct-related artery, and also demonstrated that the cost of the thrombolytic agent had relatively little effect on the total cost of myocardial infarction. There could be a potential saving by shortening hospitalization, which accounted for half the cost of thrombolysed myocardial infarction.

Key Words: Myocardial infarction • thrombolytic treatment • economic evaluation • cost effectiveness


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