Cost effectiveness of invasive strategy in unstable coronary disease--what are we waiting for?

Despite years of enquiry and thousands of publications, best practice in the management of unstable coronary disease remains uncertain. In particular, is it best to adopt a practice of routine early catheterization with revascularization as appropriate (a socalled, ‘invasive strategy’), or restrict catheterization and revascularization to those with evidence of spontaneous or inducible ischaemia (a so-called, ‘conservative strategy’)? It is well known that patterns vary widely, especially from country to country, but it remains unclear what effect this has on outcome, if any. Over the last few years four large trials have specifically addressed this question and have given apparently conflicting results. In this issue, Janzon et al. present an economic analysis of the well-known FRISC II invasive trial which represents the first economic analysis of any such trial to be published. The results of the FRISC II invasive trial are well known. In short, 2457 patients with non-Q wave acute coronary syndromes were treated with dalteparin for 5–7 days and then randomized to an invasive or a conservative strategy (as well as to ongoing dalteparin or placebo). At 1 year, the rate of death or MI was significantly lower in the invasive group than in the conservative group (10·4% vs 14·1%, P=0·005). Janzon et al. present a detailed analysis of the costs incurred by the actual patients in the trial over 1 year using data collected prospectively. They obtain a cost of SEK201622 (22427 Euros according to the exchange rate on 20.02.01) for the invasive strategy and SEK177746 (19771 Euros) for the conservative strategy, a difference of SEK23876 (2655 Euros) or 13%, all over 1 year. These data in turn generate an incremental cost effectiveness ratio of SEK1404000 (156174 Euros) per life saved and SEK645000 (71746 Euros) per life saved or MI averted for the invasive strategy compared with the conservative strategy.