Costs and benefits of treatment of myocardial infarction

Abstract

Few treatments have been introduced in recent decades which are as effective as the modern treatment of myocardial infarction, based on rapid diagnosis (often by ambulance personnel, before admission to a hospital), immediate referral for reperfusion therapy (preferably by PCI), early discharge and subsequent intensive medical treatment for secondary prevention. The need for immediate PCI places a great burden on the medical staff (interventional cardiologists, nurses, technicians) of the hospital since many procedures need to be performed outside ‘normal’ working hours. Nevertheless such treatment is offered to most patients in the Netherlands admitted with ST-segment elevation on the ECG (STEMI) because the benefits are undisputable. Long-term follow-up of the study of reperfusion therapy by the Interuniversity Cardiology Institute in The Netherlands (ICIN) revealed that the early benefits of reperfusion therapy were sustained during 20 years, with a gain in life expectancy of 2.8 years [1]! The additional costs of reperfusion therapy during the first year after hospital admission were estimated at Dfl 7000 (€ 3200) [2], which amounts to only Dfl 2500 (€ 1150) per life-year saved! Further improvement of therapy for myocardial infarction was achieved by primary PCI as developed in Zwolle [3]. Indeed, systematic application of primary PCI resulted in a major further improvement of survival. For example, survival after 3 years of patients admitted with STEMI to the Thoraxcentre improved from 75% in the last decade of the previous century to 87% thereafter [4]. This represents a 48% reduction in mortality! In this issue of the journa lS oekhlal et al. report an analysis of current treatment costs of myocardial infarction in the Netherlands [5]. According to their calculations treatment costs for STEMI including PCI are about € 5700 and for patients with STEMI treated without PCI about € 4300. This is a modest difference of € 1400, well worth the benefits. Direct PCI is very cost-effective therapy. However, to my regret, the authors do not mention these benefits and present only costs. The authors indicate that their calculations may be used to support decision-making in health care, but such decision-making should also take into account the benefits of the treatment. Indeed, treatment of myocardial infarction carries a cost, but it should be seen as investment, an investment in health, an investment resulting in a significantly improved longevity and quality of life! Few interventions are as cost-effective as primary PCI.