Atrial fibrillation: persistent: DC cardioversion followed by amiodarone maintenance was most cost-effective

Clinical bottom line (level 1b)

  1. The most cost-effective treatment for patients with persistent atrial fibrillation was electrical cardioversion followed by amiodarone maintenance.
  2. Flecainide or ibutilide were the most cost-effective methods of pharmacological cardioversion.
  3. Warfarin was more cost-effective than aspirin for patients with one risk factor for stroke.
  4. One attempt at electrical cardioversion was more cost-effective than starting antithrombotic therapy without any attempt.
McNamara et al: AHRQ Evidence Report 2001; 12 : -
Expires November 2003

The study

cost-effectiveness study based on a decision-analysis using a Monte Carlo multistate transition model
Setting: acute hospitals

systematic review of literature of pharmacological and electrical intervention for cardioversion and subsequent maintenance of sinus rhythm. Options included
  • electrical cardioversion without subsequent pharmacological therapy
  • pharmacological conversion using either quinidine, flecainide, propafenone, amiodarone, sotalol, or ibutilide without subsequent pharmacological therapy.
  • pharmacological conversion with continued therapy using either quinidine, flecainide, propafenone, amiodarone, or sotalol
  • electrical cardioversion with subsequent maintenance of sinus rhythm using one of the five agents listed above.
followed by warfarin or aspirin

  • Viewpoint: society
  • Benefit assessment: cardioversion, maintenance of sinus rhythm, bleeding, TIA/stroke, ventricular arrhythmia, death
  • Resources and costs: 1997 US dollars using the Medical Economics Index. Costs and utilities were discounted by 3% per year.
  • Sensitivity analysis: Sensitivity analysis was performed by varying patient risk factors, setting of care (inpatient v. outpatient)
    • A cost of < $50,000 per quality-adjusted life-year was considered cost-effective.

    The evidence

    intervention cost
    electrical cardioversion followed by amiodarone maintenance $18100
    flecainide cardioversion and maintenance $34410

    Effect of sensitivity analysis: The cost-effectiveness results were influenced by varying the cost of inpatient treatment and the efficacy of individual antiarrhythmic agents. The likelihood of ischaemic stroke and the effect on quality of life affected the cost-effectivenss of warfarin compared with aspirin.
    • Flecainide and ibutilide were more expensive than electrical cardioversion for acute cardioversion, but were nearly as effective.
    • Warfarin was found to be more cost-effective than aspirin for any patient with a risk-factor.
    • Attempting cardioversion at least once compared was more cost-effective than antithrombotic therapy without cardioversion.

    Comments

    1. Reporting of adverse effects or reasons for withdrawal was inconsistent.
    2. 8 non-English language articles were found, but full articles were not retrieved or combined in the meta-analysis.
    3. Most studies were small (< 100 patients), and study populations, drug administration, and length of follow-up varied greatly.
    4. 11 studies included patients with atrial flutter

    Citation

    1. McNamara RL, Bass EB, Miller MR, et al: Management of New Onset Atrial Fibrillation. Evidence Report/Technology Assessment No. 12 (prepared by the Johns Hopkins University Evidence-based Practice Center in Baltimore, MD, under Contract No. 290-97-0006). AHRQ Publication Number 01-E026. Rockville, MD: Agency for Healthcare Research and Quality.. AHRQ Evidence Report 2001; 12 : -
    Search Terms: from AHRQ website
    Contributor: Chris Ball, November 2001
    Reviewer:

    Clinical Question.
    Patient persisitent atrial fibrillation
    Intervention or Exposure electrical or pharmacological cardioversion with warfarin or aspirin
    Outcome sinus rhythm, stroke, bleeding, death
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