Epidemiological, clinical, and economic burden of myocardial infarction patients in Iran during the COVID-19 pandemic.

Background: To define changes in AMI case rates, patient demographics, cardiovascular comorbidities, treatment approaches, in-hospital outcomes, and the economic burden of COVID-19 during the pandemic. Methods: We conducted a multicenter, observational survey with selected hospitals from three medical universities in Tehran city. A data collection tool consisting of three parts. The first part included socio-demographic information, and the second part included clinical information, major complications, and in-hospital mortality. Finally, the third part was related to the direct medical costs generated by AMI in COVID-19 and non-COVID-19 patients. The study cohort comprised 4,560 hospitalizations for AMI (2,935 for STEMI [64%] and 1,625 for NSTEMI [36%]). Results: Of those hospitalized for AMI, 1,864 (76.6 %) and 1,659 (78 %) were male before the COVID-19 outbreak and during the COVID-19 era, respectively. The length of stay (LOS), was significantly lower during the COVID-19 pandemic era (4.27 ± 3.63 vs 5.24 ± 5.17, p = 0.00). Results showed that there were no significant differences in terms of patient risk factors across periods. A total of 2,126 AMIs were registered during the COVID-19 era, with a 12.65 % reduction (95 % CI 1.5-25.1) compared with the equivalent time in 2019 (P = 0.179). The risk of in-hospital mortality rate for AMI patients increased from 4.9 % in 2019 to 7.0 % in the COVID-19 era (OR = 1.42; 95 % CI 1.11-1.82; P = 0.004). Major complications were registered in 9.7 % of cases in 2020, which is higher than the rate of 6.6 % reported in 2019 (OR = 1.46, 95 % CI 1.11-1.82; P = 0.000). Total costs in hospitalized AMI-COVID patients averaged $188 more than in AMI patients (P = 0.020). Conclusion: This cross-sectional study found important changes in AMI hospitalization rates, worse outcomes, and higher costs during the COVID-19 periods. Future studies are recommended to examine the long-term outcomes of hospitalized AMI patients during the COVID-19 era.

Cost-effectiveness of cardiovascular magnetic resonance imaging compared to common strategies in the diagnosis of coronary artery disease: a systematic review.

Cardiovascular magnetic resonance imaging (CMR) has established exceptional diagnostic utility and prognostic value in coronary artery disease (CAD). An assessment of the current evidence on the cost-effectiveness of CMR in patients referred for the investigation of CAD is essential for developing an economic model to evaluate the cost-effectiveness of CMR in CAD. We conducted a comprehensive search of multiple electronic databases, including PubMed, Scopus, Web of Science core collection, Embase, National Health Service Economic Evaluation Database (NHS EED), and health technology assessment, to identify relevant literature. After removing duplicates and screening the title/abstract, a total of 13 articles were deemed eligible for full-text assessment. We included studies that reported one or more of the following outcomes: incremental cost-effectiveness ratio (ICER), cost per quality-adjusted life year (QALYs), cost per life year gained, sensitivity and specificity rate as the primary outcome, and health utility measures or health-related quality of life as the secondary outcome. The quality of the included studies was assessed using the CHEERS 2022 guidelines. The findings of this study demonstrate that in patients undergoing urgent percutaneous coronary intervention, CMR over a one-year and lifetime horizon leads to higher quality-adjusted life years (QALYs) compared to current strategies in cases of multivessel disease. The systematic review indicates that the CMR-based strategy is more cost-effective when compared to standard methods such as single-photon emission computed tomography (SPECT), coronary computed tomography angiography (CCTA), and coronary angiography (CA) (CMR = $19,273, SPECT = $19,578, CCTA = $19,886, and immediate CA = $20,929). The results also suggest that the CMR strategy can serve as a cost-effective gatekeeping tool for patients at risk of obstructive CAD. A CMR-based strategy for managing patients with suspected CAD is more cost-effective compared to both invasive and non-invasive strategies, particularly in real-world patient populations with a low to intermediate prevalence of the disease.

Cost-Effectiveness of Sacubitril/Valsartan Compared with Enalapril in Patients with Heart Failure with Reduced Ejection Fraction: A Systematic Review.

Background: To assess the cost-effectiveness of sacubitril/valsartan compared with enalapril in patients with heart failure with reduced ejection (HFrEF). Methods: A systematic literature search was conducted searching in major electronic databases from inception to January 1, 2021. All relevant full economic evaluation studies of sacubitril/valsartan versus enalapril for the treatment of patients with HFrEF were identified using ad hoc search strategies. Mortality, hospital admissions, quality-adjusted life years (QALYs), life-years (LYQs), annual drug costs, total lifetime costs, and incremental cost-effectiveness ratio (ICER) were considered as the outcomes. The quality of the included studies was assessed using the CHEERS checklist. This study was conducted and reported in accordance with the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" (PRISMA) guidelines. Results: The initial search yielded a pool of 1026 articles, of which 703 unique articles were screened, 65 full-text articles were assessed for eligibility and 15 studies finally included in the qualitative synthesis. Studies show that sacubitril/valsartan reduces mortality and hospitalization rate. The mean of death risk ratio and hospitalization were computed at 0.843 and 0.844, respectively. Sacubitril/valsartan produced higher annual and total lifetime costs. The lowest and highest lifetime costs for sacubitril/valsartan were found in Thailand ($4,756) and Germany ($118,815), respectively. The lowest ICER was reported in Thailand ($4857/QALY) and the highest in the USA ($143,891/QALY). Conclusion: Sacubitril/valsartan is associated with better outcomes and may be cost-effective compared to enalapril for the management of HFrEF. However, in developing countries such as Thailand, sacubitril-valsartan costs must be reduced to yield an ICER below the threshold.

Burden of Hypertensive Heart Disease in Iran during 1990-2017: Findings from the Global Burden of Disease study 2017.

BACKGROUND: Hypertension and its consequent end-organ damage including Hypertensive Heart Disease (HHD) are a major concern that impact health, resulting into impairment and reduced quality of life (QOL). The purpose of this study was to describe the burden of HHD in Iran and comparing it with the World Bank upper middle-income countries (UMICs) in terms of disability-adjusted life years (DALY), mortality and prevalence. METHODS: Using data from the Global Burden of Disease study 2017, we compared the number of DALYs, deaths and prevalence trends for HHD from 1990 to 2017 in all age groups for both sex in Iran, and compared the epidemiology and trends with UMICs and globally. RESULTS: The age-standardized DALY rate for HHD increased by 51.6% for men (95% uncertainty interval [UI] 305.8 to 436.7 per 100,000) and 4.4% for women (95% UI 429.4 to 448.7 per 100,000) in Iran. The age-standardized prevalence of HHD in Iran was almost twice times higher than globally and 1.5-times more than the World Bank UMICs. The age-standardized death rate for HDD increased by 60.1% (95% UI 17.3 to 27.7% per 100,000) for men and by 21.7% (95% UI 25.85 to 31.48 per 100,000) for women from 1990 to 2017. Age-standardized death rate in Iran was 2.4 and 1.9 times higher than globally and UMICs, respectively. CONCLUSIONS: The higher prevalence and death rate in Iran in comparison with UMICs and globally should encourage health care provider to perform intensive screening activities in at risk population to prevent HHD and mitigate its mortality.

Cost-effectiveness analysis of mitral valve repair with the MitraClip delivery system for patients with mitral regurgitation: a systematic review.

To assess the cost-effectiveness of mitral valve repair with the MitraClip delivery system for patients with mitral regurgitation and heart failure, a systematic literature search was conducted in various electronic databases to January 3, 2020. Eligibility criteria are the population (patients with mitral regurgitation (MR)), intervention (transcatheter mitral valve repair using the MitraClip), comparator (conventional medical treatment), outcomes, and designs (Model-based or trial-based full economic evaluations).The quality of included studies was assessed using the CHEERS checklist. Mortality and survival rate, quality-adjusted life year (QALY), life years gained (LYG), total cost, and the incremental cost-effectiveness ratio (ICER) regarding the use of MitraClip System were considered as the key outcomes. Eight articles were eligible for full-text assessment. Ultimately, a total of seven studies were considered in the current systematic review. Results demonstrated that MitraClip reduces mortality rate and increases survival rate. The mortality rate at 1 year and 10 years was 16.7% versus 29.77% and 70.9% versus 98.8%, respectively. Total cost data based on 2019 USD show that the MitraClip has the highest cost in the USA ($121,390) and the lowest cost in Italy ($33,062). The results showed that in all selected countries, willingness-to-pay (WTP) thresholds are upper than the cost per QALY; also, the highest ICER for the MitraClip is in the USA ($55,600/QALY) and the lowest in Italy ($10,616/QALY). To conclude, evidence from this systematic review suggests that MitraClip Delivery System improved both life expectancy and QALY compared with medical treatment in patients at high surgical risk and it was also a cost-effective treatment option for patients with mitral regurgitation.

Cost-effectiveness analysis of PCSK9 inhibitors in cardiovascular diseases: a systematic review.

AIMS: To assess the cost-effectiveness of pro-protein convertase subtilisin/kexin type 9 (PCSK9) inhibitors in cardiovascular disease. METHODS AND RESULTS: We performed a comprehensive search strategy in electronic databases from January 2015 to January 2019. Out of 475 articles, 16 were entered into the study. Quality-adjusted life year, life years gained (LYG), annual cost, and the incremental cost-effectiveness ratio (ICER) regarding the use of PCSK9 inhibitors were considered as the key outcomes. The cost-effectiveness threshold varied from $45,000 in Spain to $150,000 in the USA. The annual cost of PCSK9 inhibitors for studies undertaken in the USA was in the range of $14,000 to $15,000, while it was about $7000 for other developed countries. The results showed that reduction in the price of PCSK9 inhibitors changed from 20 to 88%. The means of QALY were 0.65 and 0.67 in the Markov and Cardiovascular Disease Policy Modeling (CVDPM) models; also, the ICER means were $197,707 and $625,555 for the Markov and CVDPM model, respectively. CONCLUSION: According to the current study, the effectiveness of PCSK9 inhibitors is well documented, although all studies pointed out a higher cost of these inhibitors. TRIAL REGISTRATION: This study was registered within the International Prospective Register of Systematic Reviews (PROSPERO) database of the University of York (CRD42018088472).

A systematic review of the cost-effectiveness of heart valve replacement with a mechanical versus biological prosthesis in patients with heart valvular disease.

Heart valve disease (HVD) affects 2.5% of the US population and one million individuals aged 65 years and older in the UK. Given its burden, the aim of the present review was to assess the cost-effectiveness of heart valve replacement with mechanical versus biological prosthesis in HVD patients. We performed a systematic search in various electronic databases from January 1990 to June 2019. Five out of 542 articles were entered into the study, from which 2 papers were subsequently excluded not meeting the minimum number of items of the CHEERS checklist. Quality-Adjusted Life Year, Life Years Gained, and the Incremental Cost-Effectiveness Ratio (ICER) regarding the type of replaced heart valve were extracted and reported. Studies were conducted in three different countries (Iran, France, and USA). ICER ranged from $1253 in Iran to €54,634 in France. Survival rate of mitral mechanical versus biological valves at 10 and 20 years was 72.9% versus 76.0% and 51% versus 30%, respectively. Survival rate at 20 years in patients undergoing atrial valve replacement was 20%. Ten- and 20-year death rates for biological valves were higher with respect to mechanical prosthesis (15.5% versus 8.4% at 10 years), with this difference becoming more relevant at 20 years (36.9% versus 13.9%). Due to higher ICER, mortality rate, and lower success rates in the long term for biological prostheses compared to mechanical ones, these appear to be more suitable for older patients (aged ≥ 70 years).