Cost-effectiveness of genotype-guided and dual antiplatelet therapies in acute coronary syndrome

Ann Intern Med. 2014 Feb 18;160(4):221-32. doi: 10.7326/M13-1999.


Background: The choice of antiplatelet therapy after acute coronary syndrome (ACS) is complicated: Ticagrelor and prasugrel are novel alternatives to clopidogrel, patients with some genotypes may not respond to clopidogrel, and low-cost generic formulations of clopidogrel are available.

Objective: To determine the most cost-effective strategy for dual antiplatelet therapy after percutaneous coronary intervention for ACS.

Design: Decision-analytic model.

Data sources: Published literature, Medicare claims, and life tables.

Target population: Patients having percutaneous coronary intervention for ACS.

Time horizon: Lifetime.

Perspective: Societal.

Intervention: Five strategies were examined: generic clopidogrel, prasugrel, ticagrelor, and genotyping for polymorphisms of CYP2C19 with carriers of loss-of-function alleles receiving either ticagrelor (genotyping with ticagrelor) or prasugrel (genotyping with prasugrel) and noncarriers receiving clopidogrel.

Outcome measures: Direct medical costs, quality-adjusted life years(QALYs), and incremental cost-effectiveness ratios (ICERs).

Results of base-case analysis: The clopidogrel strategy produced$179 301 in costs and 9.428 QALYs. Genotyping with prasugrel was superior to prasugrel alone, with an ICER of $35 800 per QALY relative to clopidogrel. Genotyping with ticagrelor was more effective than genotyping with prasugrel ($30 200 per QALY relative to clopidogrel). Ticagrelor was the most effective strategy($52 600 per QALY relative to genotyping with ticagrelor).

Results of sensitivity analysis: Stronger associations between genotype and thrombotic outcomes rendered ticagrelor substantially less cost-effective ($104 800 per QALY). Genotyping with prasugrel was the preferred therapy among patients who could not tolerate ticagrelor.

Limitation: No randomized trials have directly compared genotyping strategies or prasugrel with ticagrelor.

Conclusion: Genotype-guided personalization may improve the cost-effectiveness of prasugrel and ticagrelor after percutaneous coronary intervention for ACS, but ticagrelor for all patients may bean economically reasonable alternative in some settings.

Publication types

  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Acute Coronary Syndrome / drug therapy*
  • Acute Coronary Syndrome / surgery
  • Adenosine / adverse effects
  • Adenosine / analogs & derivatives
  • Adenosine / economics
  • Adenosine / therapeutic use
  • Alleles
  • Aryl Hydrocarbon Hydroxylases / genetics
  • Clopidogrel
  • Coronary Thrombosis / prevention & control
  • Cost-Benefit Analysis
  • Cytochrome P-450 CYP2C19
  • Decision Support Techniques
  • Direct Service Costs
  • Drug Therapy, Combination
  • Drugs, Generic / adverse effects
  • Drugs, Generic / economics
  • Drugs, Generic / therapeutic use
  • Genotype
  • Hemorrhage / chemically induced
  • Humans
  • Percutaneous Coronary Intervention
  • Piperazines / adverse effects
  • Piperazines / economics
  • Piperazines / therapeutic use
  • Platelet Aggregation Inhibitors / adverse effects
  • Platelet Aggregation Inhibitors / economics*
  • Platelet Aggregation Inhibitors / therapeutic use*
  • Polymorphism, Genetic
  • Prasugrel Hydrochloride
  • Quality-Adjusted Life Years
  • Risk Factors
  • Thiophenes / adverse effects
  • Thiophenes / economics
  • Thiophenes / therapeutic use
  • Ticagrelor
  • Ticlopidine / adverse effects
  • Ticlopidine / analogs & derivatives
  • Ticlopidine / economics
  • Ticlopidine / therapeutic use


  • Drugs, Generic
  • Piperazines
  • Platelet Aggregation Inhibitors
  • Thiophenes
  • Clopidogrel
  • Aryl Hydrocarbon Hydroxylases
  • CYP2C19 protein, human
  • Cytochrome P-450 CYP2C19
  • Prasugrel Hydrochloride
  • Ticagrelor
  • Adenosine
  • Ticlopidine