• G D Sanders, M A Hlatky, N R Every, K M McDonald, P A Heidenreich, L S Parsons, and D K Owens.
• Center for Primary Care and Outcomes Research, 179 Encina Commons, Stanford University, Stanford, CA 94305-6019, USA. sanders@stanford.edu
• Ann. Intern. Med. 2001 Nov 20; 135 (10): 870-83.

BackgroundClinical trials have shown that implantable cardioverter defibrillators (ICDs) improve survival in patients with sustained ventricular arrhythmias.ObjectiveTo determine the efficacy necessary to make prophylactic ICD or amiodarone therapy cost-effective in patients with myocardial infarction.DesignMarkov model-based cost utility analysis.Data SourcesSurvival, cardiac death, and inpatient costs were estimated on the basis of the Myocardial Infarction Triage and Intervention registry. Other data were derived from the literature.Target PopulationPatients with past myocardial infarction who did not have sustained ventricular arrhythmia.Time HorizonLifetime.PerspectiveSocietal.InterventionsICD or amiodarone compared with no treatment.Outcome MeasuresLife-years, quality-adjusted life-years (QALYs), costs, number needed to treat, and incremental cost-effectiveness.Results Of Base Case AnalysisCompared with no treatment, ICD use led to the greatest QALYs and the highest expenditures. Amiodarone use resulted in intermediate QALYs and costs. To obtain acceptable cost-effectiveness thresholds (Results Of Sensitivity AnalysisFor moderate efficacies, in patients with ejection fractions less than or equal to 0.3, 0.31 to 0.4, and greater than 0.4, the cost-effectiveness of amiodarone compared with no therapy was $43,100/QALY, $66,500/QALY, and $132,500/QALY, respectively, and the cost-effectiveness of ICD compared with amiodarone was $71,800/QALY, $195,700/QALY, and $557,900/QALY, respectively.ConclusionsUse of ICD or amiodarone in patients with past myocardial infarction and severely depressed left ventricular function may provide substantial clinical benefit at an acceptable cost. These results highlight the importance of clinical trials of ICDs in patients with low ejection fractions who have had myocardial infarction.

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