Article Text

Download PDFPDF
Original article
Cost-effectiveness of percutaneous coronary intervention versus bypass surgery from a Dutch perspective
  1. Ruben L Osnabrugge1,2,
  2. Elizabeth A Magnuson1,
  3. Patrick W Serruys3,
  4. Carlos M Campos3,4,
  5. Kaijun Wang1,
  6. David van Klaveren5,
  7. Vasim Farooq3,
  8. Mouin S Abdallah1,
  9. Haiyan Li1,
  10. Katherine A Vilain1,
  11. Ewout W Steyerberg5,
  12. Marie-Claude Morice6,
  13. Keith D Dawkins7,
  14. Friedrich W Mohr8,
  15. A Pieter Kappetein2,
  16. David J Cohen1
  17. on behalf of the SYNTAX trial investigators
  1. 1Department of Cardiovascular Research, Saint Luke’s Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA
  2. 2Department of Cardio-Thoracic Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
  3. 3Department of Cardiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
  4. 4Heart Institute (InCor), University of São Paulo Medical School, Sao Paulo, Brazil
  5. 5Department of Public Health, Erasmus University Medical Centre, Rotterdam, The Netherlands
  6. 6Department of Interventional Cardiology, Institut Jacques Cartier, Massy, France
  7. 7Boston Scientific Corporation, Natick, Massachusetts, USA
  8. 8Department of Cardiac Surgery, Herzzentrum Universität Leipzig, Leipzig, Germany
  1. Correspondence to David J Cohen, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City School of Medicine, 4401 Wornall Rd, Kansas City, MO 64111, USA; dcohen{at}


Aims Recent cost-effectiveness analyses of percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) have been limited by a short time horizon or were restricted to the US healthcare perspective. We, therefore, used individual patient-level data from the SYNTAX trial to evaluate the cost-effectiveness of PCI versus CABG from a European (Dutch) perspective.

Methods and results Between 2005 and 2007, 1800 patients with three-vessel or left main coronary artery disease were randomised to either CABG (n=897) or PCI with drug-eluting stents (DES; n=903). Costs were estimated for all patients based on observed healthcare resource usage over 5 years of follow-up. Health state utilities were evaluated with the EuroQOL questionnaire. A patient-level microsimulation model based on Dutch life-tables was used to extrapolate the 5-year in-trial data to a lifetime horizon. Although initial procedural costs were lower for CABG, total initial hospitalisation costs per patient were higher (€17 506 vs €14 037, p<0.001). PCI was more costly during the next 5 years of follow-up, due to more frequent hospitalisations, repeat revascularisation procedures and higher medication costs. Nevertheless, total 5-year costs remained €2465/patient higher with CABG. When the in-trial results were extrapolated to a lifetime horizon, CABG was projected to be economically attractive relative to DES-PCI, with gains in both life expectancy and quality-adjusted life expectancy. The incremental cost-effectiveness ratio (ICER) (€5390/quality-adjusted life year (QALY) gained) was favourable and remained <€80 000/QALY in >90% of the bootstrap replicates. Outcomes were similar when incorporating the prognostic impact of non-fatal myocardial infarction and stroke, as well as across a broad range of assumptions regarding the effect of CABG on post-trial survival and costs. However, DES-PCI was economically dominant compared with CABG in patients with a SYNTAX Score ≤22 or in those with left main disease. In patients for whom the SYNTAX Score II favoured PCI based on lower predicted 4-year mortality, PCI was also economically dominant, whereas in those patients for whom the SYNTAX Score II favoured surgery, CABG was highly economically attractive (ICER range, €2967 to €3737/QALY gained).

Conclusions For the broad population with three-vessel or left main disease who are candidates for either CABG or PCI, we found that CABG is a clinically and economically attractive revascularisation strategy compared with DES-PCI from a Dutch healthcare perspective. The cost-effectiveness of CABG versus PCI differed according to several anatomic factors, however. The newly developed SYNTAX Score II provides enhanced prognostic discrimination in this population, and may be a useful tool to guide resource allocation as well.

Trial registration number Clinical trial unique identifier: NCT00114972 (

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.