Cost-effectiveness of everolimus-eluting versus bare-metal stents in ST-segment elevation myocardial infarction: An analysis from the EXAMINATION randomized controlled trial

PLoS One. 2018 Aug 16;13(8):e0201985. doi: 10.1371/journal.pone.0201985. eCollection 2018.


Background: Use of everolimus-eluting stents (EES) has proven to be clinically effective and safe in patients with ST-segment elevation myocardial infarction but it remains unclear whether it is cost-effective compared to bare-metal stents (BMS) in the long-term. We sought to assess the cost-effectiveness of EES versus BMS based on the 5-year results of the EXAMINATION trial, from a Spanish health service perspective.

Methods: Decision analysis of the use of EES versus BMS was based on the patient-level clinical outcome data of the EXAMINATION trial. The analysis adopted a lifelong time horizon, assuming that long-term survival was independent of the initial treatment strategy after the end of follow-up. Life-expectancy, health-state utility scores and unit costs were extracted from published literature and publicly available sources. Non-parametric bootstrapping was combined with probabilistic sensitivity analysis to co-assess the impact of patient-level variation and parameter uncertainty. The main outcomes were total costs and quality-adjusted life-years. The incremental cost-effectiveness ratio was expressed as cost per quality-adjusted life-years gained. Costs and effects were discounted at 3%.

Results: The model predicted an average survival time in patients receiving EES and BMS of 10.52 and 10.38 undiscounted years, respectively. Over the life-long time horizon, the EES strategy was €430 more costly than BMS (€8,305 vs. €7,874), but went along with incremental gains of 0.10 quality-adjusted life-years. This resulted in an average incremental cost-effectiveness ratio over all simulations of €3,948 per quality-adjusted life-years gained and was below a willingness-to-pay threshold of €25,000 per quality-adjusted life-years gained in 86.9% of simulation runs.

Conclusions: Despite higher total costs relative to BMS, EES appeared to be a cost-effective therapy for ST-segment elevation myocardial infarction patients due to their incremental effectiveness. Predicted incremental cost-effectiveness ratios were below generally acceptable threshold values.

Trial registration: NCT00828087.

Publication types

  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Cost-Benefit Analysis
  • Drug-Eluting Stents / economics*
  • Everolimus / administration & dosage
  • Follow-Up Studies
  • Health Care Costs
  • Humans
  • Patient Outcome Assessment
  • Proportional Hazards Models
  • ST Elevation Myocardial Infarction / epidemiology*
  • ST Elevation Myocardial Infarction / mortality
  • ST Elevation Myocardial Infarction / therapy
  • Stents / economics*


  • Everolimus

Associated data


Grant support

The EXAMINATION trial (NCT00828087) was funded by the Spanish Heart Foundation. SB has received speakers’ fees from Abbott Vascular and St Jude Medical. MV has received an honorarium as a public speaker for Terumo, the Medicines Company, Medtronic, Iroko, Merck, Abbott, Ely Lilly, AstraZeneca, Cordis, Carbostent and Implantable Devices, and Bayer. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The other authors declare no competing interests.