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The primacy of clinical effectiveness for cost effectiveness analysis
  1. I P Casserly,
  2. E J Topol
  1. Department of Cardiovascular Medicine, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
  1. Correspondence to:
    Eric J Topol MD, Department of Cardiovascular Medicine, Desk F25, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA;

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Cost effectiveness analysis has increasingly emerged as a means of evaluating new treatments with superior clinical outcomes but increased cost compared with the standard therapy

Despite the many advances in cardiovascular therapeutics over the last two decades, the incidence of death or myocardial infarction in the six months following clinical presentation with acute coronary syndromes (ACS) (excluding ST elevation myocardial infarction) remains unacceptably high at 12–15% (fig 1).1 Most ACS trials have focused on reducing ischaemic events during the in-hospital treatment phase (usually less than one week). However, the recognition that 40% of all deaths and myocardial infarctions (MI) in the six months after presentation with ACS occur beyond the seventh day has prompted the search for treatments specifically directed at decreasing ischaemic events beyond the acute treatment phase.

Figure 1

Incidence of death, myocardial infarction (MI), and the composite of death/MI at various time points from presentation with acute coronary syndromes in patients enrolled in the PRISM-PLUS trial.1

Several key observations have suggested the coagulation cascade should be an attractive target for such treatments: the demonstration of a persistent prothrombotic state as reflected by raised concentrations of fibrinopeptide1+2 (a marker of factor Xa activity) up to six months following an ACS,2 the angioscopic finding of persistent thrombus on infarct related plaques in 80% of patients up to one month following MI, and …

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