Juan Manuel Senior

Cost-effectiveness analysis of ticagrelor compared to clopidogrel for the treatment of patients with acute coronary syndrome in Colombia

INTRODUCTION Acute coronary syndrome is one of the most frequent medical emergencies in developing countries. OBJECTIVE To determine, from the perspective of the Colombian health system, the cost-effectiveness of ticagrelor compared to clopidogrel for the treatment of patients with acute coronary syndrome. MATERIALS AND METHODS We conducted a cost-effectiveness analysis from the perspective of the Colombian health system comparing ticagrelor and clopidogrel for the treatment of patients with acute coronary syndrome. To estimate the expected costs and outcomes, a Markov model was constructed in which patients could remain stable without experiencing new cardiovascular events, suffer from a new event, or die. For the baseline case, a 10-year time horizon and a discount ratio of 3% for costs and benefits were adopted. The transition probabilities were extracted from the PLATO (Platelet Inhibition and Patient Outcomes) clinical trial. Vital statistics were drawn from the Departmento Administrativo Nacional de Estadística (DANE) and additional information from Colombian patients included in the Access registry. To identify and measure resource use, a standard case was built by consulting guidelines and protocols. Unit costs were obtained from Colombian rate lists. A probabilistic sensitivity analysis was conducted in which costs were represented by a triangular distribution, and the effectiveness through a beta distribution. RESULTS In the base case, the additional cost per quality-adjusted life-year gained with ticagrelor was COP

Falla cardíaca de alto débito por fístulas arteriovenosas sistémicas en paciente con síndrome de Osler-Weber-Rendu

28,411,503. The results were sensitive to changes in the time horizon and the unit cost of clopidogrel. For a willingness-to-pay equivalent to three times the Colombian per capita gross domestic product, the probability of ticagrelor being cost-effective was 75%. CONCLUSIONS Ticagrelor is a cost-effective strategy for the treatment of patients with acute coronary syndrome in Colombia.

P233 How Confident Are You In The Results Given Only One Rct? Ticagrelor Vs Clopidogrel: Case Report By Clinical Guideline On Acute Coronary Syndrome In Colombia

Paciente de 65 anos, con historia de epistaxis a repeticion, sin otros antecedentes patologicos de importancia, quien presento sintomas de un ano de evolucion consistentes en disnea de esfuerzo progresiva hasta el reposo, acompanado de ortopnea y edemas que iniciaron en miembros inferiores y progresaron hasta la anasarca. Al examen clinico llamo la atencion ingurgitacion yugular, hepatomegalia, ascitis y edemas perifericos. La piel presento telangiectasias en extremidades y mucosas. Se realizaron estudios que reportaron falla cardiaca con severa dilatacion de las cavidades derechas, con funcion sistolica del ventriculo izquierdo conservada. Se demostraron fistulas arteriovenosas en higado y pulmon. Se establecio el diagnostico de sindrome de Osler-Weber-Rendu o telangiectasia hemorragica hereditaria (THH). Se propuso cierre de fistulas por via percutanea y se planteo posible trasplante hepatico como tratamiento; sin embargo, el paciente tuvo una evolucion torpida, presento fibrilacion auricular y embolismo al sistema nervioso central y fallecio por enfermedad cerebrovascular.

P211 Systematic Review And Quality Appraisal Of Clinical Practice Guidelines For The Treatment Of Patients With Acute Coronary Syndrome

Background Ticagrelor is oral antagonist of adenosine diphosphate receptors of subtype P2Y12. It is indicated for the prevention of atherothrombotic events in adults with acute coronary syndromes (ACS) and it act faster and shorter than clopidogrel. Objectives The authors review and discuss clinical findings and health-economic evidence of ticagrelor compared with clopidogrel to reduced myocardial infarction, stroke or death, major bleeding, in patients with ACS in Colombia, when only one RCT has been published comparing both drugs. Methods This question was part of the guideline development. The process included search, assessment, rating the quality of evidence and economic evaluation. The recommendations were classified according to the methodology described by GRADE Working Group: consideration benefit/harm, preferences and resources. Results 1 clinical study was identified. The efficacy outcome was favourable for the group of patients receiving ticagrelor. The result of the economic analysis suggests that the probability of ticagrelor is a cost effective alternative in the Colombian health system is more than 76.6%. Discussion We recommend ticagrelor plus ASA for patients with non-STEMI, intermediate to high-risk, and for patients with STEMI if they have not received fibrinolysis in the last 24 hours. Implications for Guideline Developers/Users Our results hold in different scenarios and sensitivity analyses, as long as the time horizon is not limited to short-term assessment because may underestimate the costs and benefits and therefore lead to erroneous conclusions with a single primarily study. Our recommendation is strong, although there was a single RCT owing to time horizon and high quality of evidence.

Comparación de la eficacia y seguridad de la terapia combinada de cardiomioplastia celular con el factor estimulante de colonias de granulocitos en pacientes con cardiopatía isquémica en dos vías de implatación

Background In Colombia, ischemic heart disease was the leading cause of death in people over 55 years of age. In the next five years, the Colombian population over 45 years of age will triple leading to an increase in the incidence and prevalence of atherosclerotic heart disease. Under this scenario, the Colombian Ministry of Health commissioned us the development of a clinical practice guideline (CPG) for the comprehensive treatment of patients with acute coronary syndrome (ACS). Therefore, as part of this process we conducted a systematic review and a quality appraisal of the published CPGs for this condition. Methods By undertaking a systematic search of multiple databases, reviewing the reference lists of included studies and the input of experts, we identified CPG for ACS with and without ST elevation, published from 2005 to 2011. We assessed the quality of each guideline using the AGREE II instrument. Results We identified 121 CPG and assessed the quality of 28 that met the inclusion criteria. The overall average for the 28 guides in all domains was: clarity of presentation 91%, reach and objectives 78%, methodological rigour 72%, stakeholder involvement 62%, editorial independence 72%, and applicability 44%. 11 of 28 guidelines had a low methodological rigour (score less than 60%). Discussion The applicability of the guideline, that is, to provide clear identification of tools to implement the recommendations of the guideline, should be strengthened in the CPG for SCA.

Descripción clínico-epidemiológica de los pacientes con falla cardiaca aguda que consultan al servicio de urgencias

Este estudio tiene como objetivo evaluar la eficacia y seguridad de la terapia combinada de cardiomioplastia celular con el factor estimulante de colonias de granulocitos en pacientes con cardiopatia isquemica, y explorar posibles diferencias entre la via de implantacion. Metodologia Se hizo un estudio de «antes y despues» para datos longitudinales en el que se compararon variables ecocardiograficas y numero de MET alcanzados en la prueba de esfuerzo antes, dos, seis y doce meses despues del procedimiento; asi mismo, se evaluaron la mortalidad y los efectos adversos de la terapia. Se exploraron diferencias en los resultados de acuerdo con la via de implantacion intracoronaria vs. epicardica. Resultados Se incluyeron dieciocho pacientes, 62,3% hombres, cuya edad promedio fue 49,4 ± 11,7 anos y la fraccion de eyeccion promedio fue 31% ± 0,04. La implantacion se realizo por via intracoronaria en doce pacientes y por via epicardica en seis. La mediana de fraccion de eyeccion antes de la implantacion de las celulas fue de 30% con un rango intercuartil de 28%-35% y la media de los MET fue de 6 con un rango intercuartil de 5-7; ambas variables, al igual que los volumenes ventriculares de fin de diastole y sistole se incrementaron de forma significativa despues del procedimiento, con tendencia a un mayor incremento de la fraccion de eyeccion en el grupo de pacientes cuya via de implantacion fue la epicardica en comparacion con la via intracoronaria; sin embargo, el numero de pacientes en cada subgrupo impidio hacer analisis definitivos. Un paciente tuvo infeccion de la herida quirurgica y tres murieron dos meses despues de la implantacion (uno de shock septico y dos de shock cardiogenico). Conclusion En nuestro medio es factible realizar terapia combinada con cardiomioplastia celular y factor estimulante de colonias de granulocito; este es un procedimiento seguro con el que se obtiene una mejoria sostenida de la fraccion de eyeccion y los MET mas alla de los beneficios que se logran con la revascularizacion y la terapia farmacologica optima.