Tissue plasminogen activator (t-PA) has overtaken streptokinase as the preferred clot-busting (thrombolytic) agent for heart attack patients in the United States. However, a new community-based study suggests that while t-PA is clearly cost effective for some patients, it is not for others and thus should be targeted to heart attack patients most likely to benefit. The study was supported in part by the Agency for Healthcare Research and Quality (HS08212 and T32 HS00060).
Researchers from Tufts-New England Medical Center and the University of Michigan Medical Center calculated that targeting t-PA to the half of heart attack patients most likely to benefit from it could save 247 lives and $174 million nationally per year. According to their model, patients most likely to benefit were those at higher risk, where risk was defined by a multivariable model including age, the presence of diabetes, prior myocardial infarction (heart attack), and the size and location of the anterior wall myocardia infarction. Based on t-PA benefits found in the GUSTO (Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries) study and differences in patient characteristics between the GUSTO population and this study sample, the researchers generated predictions of the effectiveness and cost-effectiveness of t-PA compared with streptokinase in 921 patients who received thrombolytic therapy for heart attack.
When patients were grouped into quartiles based on their expected mortality benefit, 61 percent of the incremental mortality benefit from t-PA accrued to the top 25 percent of patients; 85 percent was accounted for by half of the patients, and only 4 percent accrued to patients in the lowest quartile. For the quartile of patients most likely to benefit, t-PA was very cost effective ($15,396 per life-year saved). However, t-Pa was not cost effective (more than $100,000 per life-year saved) for 37 percent of treated patients. Those in the lowest quartile were slightly more likely to be harmed (for example, by thrombolytic-related intracranial hemorrhage) than to benefit from t-PA.
See "Tissue plasminogen activator was cost-effective compared to streptokinase in only selected patients with acute myocardial infarction," by David M. Kent, M.D., Sandeep Vijan, M.D., Rodney A. Hayward, M.D., and others, in the Journal of Clinical Epidemiology 57, pp. 843-852, 2004.
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