JJCC-02529; No of Pages 8
Journal of Cardiology xxx (xxxx) xxx

Contents lists available at ScienceDirect

Journal of Cardiology
journal homepage: www.elsevier.com/locate/jjcc

Review

Trends in the cost-effectiveness level of percutaneous coronary
intervention: Macro socioeconomic analysis and healthtechnology assessment
Tomoyuki Takura (PhD) a,⁎, Issei Komuro (MD, FJCC) b, Minoru Ono (MD, FJCC) ca

Department of Healthcare Economics and Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japanc
Department of Cardiac Surgery, University of Tokyo Hospital, The University of Tokyo, Tokyo, Japanba r t i c l e

i n f oArticle history:
Received 15 September 2022
Accepted 15 September 2022
Available online xxxx
Keywords:
Incremental cost-effectiveness ratio
Quality-adjusted life year
Acute myocardial infarction
Left main disease
Optimal medical therapys u m m a r y
Percutaneous coronary intervention (PCI), one of the most prevalent techniques of revascularization, is a procedure that remarkably improves treatment outcomes. However, it consumes large amounts of medical resources
and has resulted in an increased socioeconomic burden due to the increasing number of target patients. In recent
years, there have been sporadic discussions, both in Japan and other countries, regarding the optimization of interventions and the perspective of medical economics. Based on this, previous studies on PCI-related costeffectiveness were reviewed in order to consider the current level of medical economics regarding PCI. Using
the databases MEDLINE and EMBASE, a survey involving data from original articles and systematic reviews
was conducted from January 2010 to August 2022. Conditions were not imposed on the evidence level due tothe paucity of studies, although ﬁeld studies were prioritized over simulation studies. The macro medical economics of acute myocardial infarction treatment, which is the primary target of PCI, were generally at an averagelevel when compared to those in other countries; however, there is room for further improvement in Japan's performance. Revascularization in a population with multivessel coronary artery disease showed that coronary artery bypass graft surgery tended to be more cost-effective than PCI in the long-term setting. However, it wassuggested that PCI may be more cost-effective in patients with SYNTAX Score ≤22 or left main artery disease. A
cost-effectiveness report for stable angina patients was not in favor of PCI over medical therapy. Moreover,there were some reports showing the medical economic superiority of early myocardial ischemia evaluation,and it was foreseen that active selection of patients will contribute to the improvement of the overall costeffectiveness of PCI. In order to further improve the socioeconomic signiﬁcance of PCI in the future, it is necessary
to aim for harmony between clinical practice and health economics.
© 2022 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction
Revascularization restores blood supply to the ischemic myocardium to reduce ongoing injury and ventricular irritability, as well as improve short- and long-term outcomes, particularly in patients withacute coronary syndrome (ACS). One of the main methods of revascularization is percutaneous coronary intervention (PCI). Against thebackground of remarkable improvement in treatment outcomes, PCI
has been widely used in Japan, and it is considered that quantitative sufﬁciency has been secured. On the other hand, PCI is a procedure that
consumes a large amount of medical resources, and has resulted in an
increased socioeconomic burden due to the increasing number of target
patients. Amid such a trend, in recent years, there have been sporadic
discussions, both in Japan and other countries, regarding the⁎ Corresponding author.
E-mail address: ttakura@m.u-tokyo.ac.jp (T. Takura).

optimization of interventions and the perspective of medical economics.
Based on the above, this paper summarizes the current costeffectiveness level of PCI and helps develop this area. Concretely, we
ﬁrst discussed macro medical economics in the area of ischemic heartdisease. Further, based on this, we compared the cost-effectiveness of
PCI with coronary artery bypass graft surgery (CABG) and medical therapy. The medical economics of myocardial ischemia assessment and intravascular ultrasound guidance during PCI was also reviewed. Based onthese ﬁndings, considerations to improve the medical economics of PCI
were added.
Background: international medical economics of ischemic heartdisease treatment
The medical systems of many countries have historically operated aspart of the social security system, owing to the high public interest fromhttps://doi.org/10.1016/j.jjcc.2022.09.011
0914-5087/© 2022 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved. This is an open access article under the CC BY-NC-ND license (http://creativecommons.
org/licenses/by-nc-nd/4.0/).

Please cite this article as: T. Takura, I. Komuro and M. Ono, Trends in the cost-effectiveness level of percutaneous coronary intervention: Macrosocioeconomic an..., Journal of Cardiology, https://doi.org/10.1016/j.jjcc.2022.09.011

T. Takura, I. Komuro and M. Ono

Journal of Cardiology xxx (xxxx) xxx
20

Thirty-day mortal i ty* afte r admi ssion to hospi tal for acute myocardial
i nfarcti on base d on l i nke d data, 2019 (%: 45 ye ars and ove r)

the necessity for all people. Further, against the backdrop of securing astable supply, the pricing of medical services has often been based on
costs. Numerous developed countries face structural issues, such as declining birth rates, aging populations, and rising costs of medical services. Thus, veriﬁcation of the clinical efﬁcacy, economic burden, andpublic price levels has become a matter of urgency [1]. Therefore, withthe aim of ensuring a smooth succession of the healthcare system to thenext generation of stakeholders, there is a growing momentum for social
consensus building on appropriate economic burdens commensuratewith the value of healthcare services. As part of this, there is growinginterest in the veriﬁcation of price levels that takes performance (costeffectiveness) into consideration [2]. The cost-effectiveness evaluation
system was introduced into the drug pricing system mainly in Europe inthe 2000s and has since spread worldwide. Against this background,discussions on value assessment and price levels in the medical ﬁeld arebeing conducted with various approaches, taking cost effectiveness into
consideration.
In particular, these themes are becoming more important in thequasi-public medical market, such as the universal health insurance
system of Japan, where medical resources consist of social premiums,
general taxes (including subsidies), and patient out-of-pocket expenses.
For example, rising drug prices and procedure fees have a structure that
rebounds on social and individual burdens. Therefore, the signiﬁcanceof comprehensively discussing phenomena and issues that straddle
both macro- and micro-aspects has been emphasized [3]. We turn ourattention to the cardiovascular ﬁeld in Japan where medical expenses
form a large part of the total national medical expenses. Not so long
ago, circulatory diseases accounted for the largest share of medical expenses, which increased year by year, accounting for 19.7 % of national
health expenditure in 2016 [4]. In the last 5-year period (2016–2020),
the number of PCI procedures increased by 0.9 % annually (adjustment:
the number of medical facilities, emergency PCI: 3.2 %) [5]. High-proﬁlecost-effectiveness evidence could be applied to macro- and microissues in this area to ensure the sustainability of systems and adequacyof resource allocation. In fact, there are several reports, mainly from outside Japan, on the medical economics of the treatment of ischemic heartdisease, which is the main target of PCI, as described later.
Based on the above background, an international comparison of
medical economic macro analyses related to the treatment of acute
myocardial infarction (AMI) is presented to provide an overview for
discussing the cost-effectiveness of PCI. Fig. 1 shows a simpliﬁed overview of the macro performance (cost-effectiveness) of AMI mortality
and medical costs. A survey conducted in 2020 covered twenty-eight
countries involved in the Organization for Economic Cooperation andDevelopment for which data aggregation was possible [7]. Cases in thetarget population were aged 45 years and older and adjusted for sex
and age. Mortality was deﬁned as the 30-day mortality connecting medical facilities along treatment. In Japan, the consolidation of medical facilities was unknown. Medical costs were scored relative to associatedhospital costs across the population (100 scale). The cost data werecorrected by the Purchasing Power Parity [8]. The countries located in
the lower left of the approximation curve (r = −0.58, p < 0.01) in theﬁgure have low mortality rates and low costs, so they are interpreted ashaving excellent cost-effectiveness. Considering the level of performancein the world, Japan is presumed to have some room for improvement.
From the above brief analysis, it can be seen that the performanceof AMI treatment varies greatly between countries. Factors such ascountry-speciﬁc demographics, health policies, medical systems, andliving environments can be imagined as contributing background factors. In addition to the pathophysiological composition, it is speculated
that differences in standard clinical protocols also play a large role. For
example, when comparing Japan and the USA, there is a report thatthe rate of elective PCI in Japan is more than double that in the USA(72.7 % vs. 33.8 %, p < 0.001) [9]. In addition, the noninvasive stresstest implementation rate for stable angina pectoris is signiﬁcantly
lower in Japan than in the USA (15.2 % vs. 55.3 %; p < 0.001) [9]. Further

r = -0.583
p < 0.01
15

Korea

Luxembourg

10
Japan
USA
UK

Denmark

Canada5
Netherland

0
0

50

100

150

200

Hospital price levels, 2017, OECD average = 100 (Score)Fig. 1. Overview of medical economic performance based on acute myocardial infarctionmortality and hospitalization costs (data obtained from countries involved in the Organization for Economic Cooperation and Development).
Healthcare systems generally tend to improve clinical performance as the level ofhealthcare resource consumption increases. In this graph, when sorted by cost effectiveness, the countries located in the lower left have good medical economy. Individual country policies should consider shifting below the asymptote, which is the global average, toensure the sustainability of the health-care system. Japanese mortality data were modiﬁedby the information of The Japanese Circulation Society [5]. Netherlands mortality data
were corrected in the related report [6].
(*) Age-sex standardised rate per 100 admissions aged 45 years and over.
a: PPPs are estimated predominantly by using salaries of medical and non-medical staff(input method).
b: 1. Data do not include deaths outside acute care hospitals.
(Source) OECD Health Statistics 2021.

investigation is required to determine the extent to which these trends
affect the macro performance of AMI treatment as described above.
However, it is easy to imagine that the clinical characteristics affectthe medical economic outcome of the area concerned. In addition, thecost-effectiveness performance of individual medical technologies,
particularly that of PCI, which is at the center of intervention, is an
important determinant of the medical economy of the area.
Methods: theory and method of cost-effectiveness evaluation
In recent years, it has been expected to illustrate the medical value in
response to the social proposition of promoting medical innovation andsustaining a universal health insurance system [3,10]. It is inferred thatthe role of cost-effectiveness can be positioned as part of this measure.
Generally, in microeconomics, price is converged, and efﬁciency ismaximized based on supply and demand equilibrium, based on utility
theory. However, while incorporating the perspective of equity withthe goal of maximizing the well-being of the population, medical
value discusses the balance between the patient's utility value (preference, willingness to pay) and medical ﬁnance (income redistribution,ﬁnancial balance) from the viewpoint of public interest (Fig. 2) [3]. As
such, this value advocates enhancing the balance between beneﬁts
and costs per health program unit, interweaving the relationship between the individual and society. As a result, if utility is maximized
within a certain budget, the higher the cost-effectiveness, the higher
the utility of the group as a whole, and the higher the real “value” of2

T. Takura, I. Komuro and M. Ono

Journal of Cardiology xxx (xxxx) xxx

Fig. 2. The concept of value evaluation of health care based on utility theory and cost-effectiveness considering welfare economics.
Medical value can be discussed, albeit in a limited way, by combining marginal utility theory and cost-effectiveness evaluation. Based on this, we will examine three important and closely
related perspectives involved in the development of the medical system in the future: An examination of universal health coverage in the light of socio-economic factors, the signiﬁcance of
citizens' value in resource allocation, and price formation considering the economic burden of patients. For example, high expectations for cost-utility evidence can be applied to macroand micro-issues to ensure the sustainability of the system and the appropriateness of resource allocation [2].

aortic valve implantation, chimeric antigen receptor T-cell therapy) towhich this evaluation was applied are still fresh in our minds.
ICER can be viewed as a “yardstick” for strictly judging “whether
cost-effectiveness is superior or inferior.” Since the standpoint of analysis is generally a social point of view, the “cost” of treatment materials is
sorted according to the standard of “medical fee claim (public price)”[11]. Usually, this cost discusses the cumulative consumption of medical
resources such as examination/diagnosis, treatment/surgery, hospitalization, rehabilitation, and medicines/medical devices. As for “effectiveness”, clinical indices, life prognosis and patient-subjective outcomes(QOL and QALY mentioned above) are selected. QALY is quantiﬁed as
1 QALY for 1-year survival in perfect health and 0 QALY for death. The
formula for ICER is the difference between the cost (b) of similar technology β and the cost (a) of new medical technology α [that is, (a–b)]
divided by the difference between the effectiveness (B) of similar technology β and the effectiveness (A) of new medical technology α [that is,(A–B)] (Fig. 3) [13,16,17]. This can be expressed, so to speak, as “howmuch additional cost is required to obtain a high additional effect?”
When utility (QALY) is selected as the outcome, it is sometimes referred
to as Incremental Cost-Utility Ratio (ICUR).
Based on the above, we collected previous research examples of costeffectiveness related to PCI. The target databases were MEDLINE andEMBASE. The survey period was from January 2010 to August 2022. The
articles included were original articles and systematic reviews. The search
queries were [PCI OR percutaneous transluminal coronary angioplasty(PTCA) AND cost-effectiveness OR health economy]. Due to the paucityof studies, constraints of evidence level were not imposed. However,reports from Japan were prioritized over those from other countries.
Additionally, ﬁeld studies were prioritized over simulation studies assimulation studies are difﬁcult to categorize into an evidence level [18].
Moreover, when sorting the literature, priority was given to the most recent reports. By the way, the ﬁrst general report of the cost-effectivenessof revascularization was the ICUR study in CABG in 1981 [14]. Henceforth,in the present paper, we standardized ICUR to ICER. This paper organizedstable coronary artery diseases and chronic coronary syndrome respecting
the original notation of each report.

stakeholders. Compared to discussing conceptual value, this approach isrelatively possible in considering the relationship with the real economy and general value, and therefore, suitable for examining medical
treatment prices in the public medical ﬁeld.
The value of health services in Japan, which is a public sector, can be
indirectly evaluated by applying marginal utility theory and preferencebased scales under conditions and objectives different from those in theprivate sector [11]. Incidentally, in the medical ﬁeld, a method formeasuring and analyzing a patient's utility value is being developed asa type of health-related quality of life. Cost-utility analysis (CUA) is anapplication of this concept to cost-effectiveness analysis (CEA). Basedon this, when a utility function is applied to cost-effectiveness, medical
value is calculated as “resource consumption (mainly direct medical
costs)/health recovery (patient outcomes such as utility)” [12]. In
addition, one of the outcomes is a global index called quality-adjusted
life years (QALYs). This is a concept that integrates a patient's
utility value and years of life, and it is an index that discusses bothquantitative (life prognosis) and qualitative outcomes (QOL) [12].
These concepts are also maintained as guidelines in the cardiovascularﬁeld by organizations such as the American Heart Association in the
USA [13,14].
This cost-effectiveness has been introduced into the medical insurance system in Japan since 2019, and it is used to verify the balance ofclinical usefulness and economic burden of drugs and medical devices
with high public prices and huge market size. In this cost-effectivenessassessment, we generally discuss the level of performance (e.g. slope).
When the dimensions and levels of effectiveness and cost differ
between the selected clinical techniques in health technology assessments, the Incremental Cost-Effectiveness Ratio (ICER) is selected,
which discusses the ratio of additional beneﬁt to increased cost (theso-called ratio of difference) [15]. Based on the consensus of the national economic burden calculated by willingness to pay and gross domestic product, the decision criteria are the allowable amount of about
5 million to 7.5 million yen per QALY acquisition [16]. This approach demands attention to analytical certainty and outcome sensitivity. The
price adjustments for expensive medical technology (e.g. transcatheter
3T. Takura, I. Komuro and M. Ono

Journal of Cardiology xxx (xxxx) xxx

Fig. 3. The concept and calculation method of the Incremental Cost-Effectiveness Ratio (ICER).
In general, the level of cost-effectiveness is expressed by the ICER. The ICER is compared to a predetermined threshold. If this value is less than the threshold, it is categorized as
cost-effective, and not cost-effective otherwise. When the intervention is less expensive and more effective, it is categorized as dominant. When it is costlier and more effective,
it is categorized as effective. If it is less expensive and effective, it is categorized as doubtful, and if it is costlier and less effective, it is categorized as inferior.

report (ICER of CABG: 16,537 US$/QALY) related to the SYNTAX trial[24]. Based on data from the EXCEL trial, CABG was an economicallysavvy strategy over a lifetime horizon for patients with signiﬁcant left
main coronary artery disease (ICER: 44,235 US$/QALY) [25]. A systematic review of 16 papers published in 2016 found that CABG was morecost-effective in the long term than PCI for complex multivessel coronary artery disease [26]. The cost-effectiveness of PCI versus CABG differed according to several anatomic factors. In the analysis related tothis theme, it is necessary to accumulate more evaluation results thatincorporate a social perspective and a time range of a lifetime or 10
years or more while considering multifaceted inﬂuential factors. For

Results: cost-effectiveness trends of PCI
Standalone cost-effectiveness trends
PCI reduces mortality in ACS patients. Therefore, many guidelines
recommend invasive therapy for all patients with ST-segment elevation
myocardial infarction (STEMI) and most patients with non-ST-elevation
ACS [19,20]. Currently, the proportion of elderly patients with ACS is
increasing, and their management should be similar to that of younger
patients. Therefore, considering its expanded use in the elderly, we
introduce a recent report on the cost-effectiveness of PCI [21].
This paper is based on a project spanning six European countries(EUROTRACS: EUROpean Treatment & Reduction of Acute Coronary
Syndrome cost analysis). This report was a modeling study (Markov
model) based on the course of disease from ﬁrst admission to death in
ACS patients aged 75 years and older. The results suggest that, compared to the current clinical practice, broadening the PCI use in elderly
ACS patients would be cost-effective across different healthcare systems
in Europe, regardless of the selected strategy [21]. For example, ICER of
providing PCI to all patients ranged from 2262.8 €/Qaly gained forGerman males to 6324.3 €/Qaly gained for Italian females. Increasing
PCI use was cost-effective at a willingness-to-pay threshold of 30,000€/Qaly gained for all scenarios in the six countries, in males and females.
As described above, standalone cost-effectiveness of PCI tends to berelatively high among life-saving interventions for ACS patients.

Comparison of PCI and CABGThe Synergy Between Percutaneous Coronary Intervention With
TAXUS and Cardiac Surgery (SYNTAX) trial demonstrated that in patients with three-vessel or left main coronary artery disease, CABG
was associated with a lower rate of cardiovascular death, myocardial infarction, stroke, or repeat revascularization when compared to PCI withdrug-eluting stents (DES) [22]. Based on this trend, there was a report ofa cost-effectiveness analysis applying SYNTAX trial data [research design: randomized clinical trial (RCT), observation period: ﬁve years][23]. Lifetime simulation results show an ICER of €5390/QALY in favorof CABG. However, DES-PCI was found to be economically dominant
when compared to CABG in patients with a SYNTAX Score ≤22 or inthose with left main artery disease (Fig. 4, Table 1). There is a similar

Fig. 4. Comparison of cost-effectiveness of percutaneous coronary intervention (PCI) andcoronary artery bypass grafting (CABG).
Joint distribution of projected lifetime incremental costs and quality-adjusted life expectancy for CABG vs PCI based on bootstrap replication of the Synergy Between PercutaneousCoronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) trial population plotted on the cost-effectiveness plane. The black circle represents the estimated mean values[incremental cost = $ 5081; incremental quality-adjusted life-year (QALY) = 0.307] [22].
4T. Takura, I. Komuro and M. Ono

Journal of Cardiology xxx (xxxx) xxx

Table 1
Cost-effectiveness comparison of percutaneous coronary intervention and coronary artery bypass grafting. Lifetime cost-effectiveness results for subgroups.
Source: Reference [23].
Cost, $

Age ≤60 y (n = 553)
Age 61–70 y (n = 586)
Age >70 y (n = 627)
Diabetes mellitus (n = 494)
No diabetes mellitus (n = 1272)
LM disease (n = 694)
3-Vessel disease (n = 1072)
SYNTAX score ≤22 (n = 562)
SYNTAX score 23–32 (n = 600)
SYNTAX score ≥33 (n = 595)
US patients (n = 241)
Non-US patients (n = 1525)

QALYs

CABG

PCI

Δ (95 % CI)

CABG PCI

105,305
92,88180,81097,787
90,38393,732
91,61995,62487,747
94,309105,396
90,500101,926
88,30373,55591,94385,644
86,11488,27092,582
83,54086,38496,01586,0863378 (−3261 to 9692)
4578 (−1070 to 10,581)
7254 (1972 to 12,302)
5843 (−378 to 12,214)4739 (908 to 8519)
7618 (2225 to 12,734)
3350 (−673 to 7368)
3043 (−2826 to 9205)
4207 (−1432 to 9544)
7925 (2740 to 13,296)
9382 (−1623 to 20,402)
4414 (1027 to 7601)

14.28
10.55
7.19
10.12
10.68
9.94
10.92
10.97
10.29
10.36
10.84
10.5

Δ (95 % CI)

13.95
0.32 (0.40 to 0.95)
10.21
0.34 (−0.44 to 1.00)
6.97
0.21 (−0.51 to 0.84)
9.53
0.59 (−0.15 to 1.28)
10.52
0.16 (−0.323 to 0.606)
10.233 −0.29 (−1.00 to 0.37)
10.24
0.68 (0.17 to 1.10)
11.17−0.20 (−0.95 to 0.46)
10.18
0.114 (−0.60 to 0.79)
9.4
0.96 (0.35 to 1.58)
10.05
0.79 (−0.30 to 1.78)
10.27
0.24 (−0.20 to 0.65)

ICER,$/QALYCABG
CABG
CABG <
Dominant, % Dominated, % $50,000, %⁎10,48813,35934,0279864
29,129PCI dominant
4905
PCI dominant
36,7908219
11,936
18,737

7.7
3.6
0.1
2.6
0.1
0
5.2
1.8
2
0.2
3.1
0.2

11.1
14.5
25.5
6.1
24.1
81.1
0.2
60.6
32.8
0.2
5.4
13.3

72.3
74
57.6
87.7
64.2
8.9
94.3
18.3
52.3
99.4
85.7
75.7

Costs and QALYs are discounted at 3 % per year. Δ indicates difference between CABG and PCI groups; CABG, coronary artery bypass grafting; CI, conﬁdence interval; ICER, incremental costeffectiveness ratio for coronary artery bypass grafting versus percutaneous coronary intervention; LM, left main; PCI, percutaneous coronary intervention; QALY, quality-adjusted life-year
gained; and SYNTAX, Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery.
⁎ Probability that CABG is the preferred strategy at a societal ICER of $50,000 per QALY gained.

signiﬁcant cost savings (AU$ 1,214,688) as compared to the femoral
access group [33]. Furthermore, according to a model analysis (observation period: two years) using data from the MATRIX trial for ACS, ICER
for transradial access PCI improved by 11.9 QALY as compared totransfemoral access PCI, and AU$ 51,305 was saved, demonstrating
good cost-effectiveness (Table 3) [34]. Next, we report on the costeffectiveness studies of DES and bare-metal stents (BMS). According
to a retrospective cohort study (database study, observation period:
ﬁve years) in patients with coronary heart disease, DES-PCI (NT$238,394 per cardiovascular death or coronary event averted) was superior to BMS-PCI (NT$ 663,000), and it was more cost-effective [35]. Similarly, although there was no signiﬁcant difference in the target vessel
revascularization/target lesion revascularization rate and EQ visual analog scale/Utility score, the ICER of DES-PCI was HK$ 187,000/QALY, suggesting that DES was economically superior, especially for STEMI ACS[36]. For reference, we introduce a modeling study that was constructedto compare the cost-effectiveness of intravascular ultrasound (IVUS) toangiography guidance [37,38]. Use of IVUS guidance during PCI is likely
to be more cost-effective as compared to angiography guidance alone inpatients with left main and complex coronary artery lesions (ICER:
36,651 AU$/QALY).

reference, the CULPRIT-SHOCK trial compared the medical economics of
immediate multivessel PCI (MV-PCI) to culprit vessel only PCI (CO-PCI,with additional staged revascularization if indicated) [27,28]. The results showed that the lifelong CUA had an ICER (CO-PCI vs. MV-PCI) of
7010 €/QALY and a probability of >64 % that CO-PCI will be the mostcost-effective strategy at a € 30,000 threshold.
Comparison of PCI and medical therapy
In the ORBITA trial (study design: RCT, observation period: 12months) that compared anti-anginal therapy (200 adult patients withstable angina and angiographically severe single-vessel coronary arterydisease) to PCI and to medical therapy (placebo group), the ICER (utility
value conversion is model analysis) of the PCI group was £90,218/QALY(Table 2) [29]. This result exceeded the £30,000 threshold used by the
UK National Institute for Health and Care Excellence when conducting
health technology assessments, proving that PCI tended to be lesscost-effective. Despite being a model study, there is a report in Japanthat analyzes the cost-effectiveness of PCI compared to drug therapy
for STEMI and angina pectoris [30]. According to this, the ICER of PCI
in the STEMI group was 0.97 million yen/QALY, and the ICER of the angina pectoris group was 4.63 million yen/QALY, which was generally
considered good. On the other hand, the ICER for asymptomatic patientswas 23 million yen/QALY, which was considered as a very poor medical
economic outcome (in Japan, the cost-effectiveness judgment standard
in the public medical insurance system is 5 million to 7.5 million yen per
1 QALY gained [16]). A prospective observational study including
patients with stable ischemic heart disease also showed that a costeffectiveness analysis (10-year long-term simulation) of adding elective
PCI compared to baseline (preoperative) treatment strategy formulation resulted in approximately 70,000 US$/QALY (probability expectedvalue) [31]. According to a simulation report (time horizon: lifetime)in 2013 that evaluated the medical economics of PCI against medical
therapy for the initial strategy in patients with stable coronary arterydisease, DES-PCI was found to be highly cost-effective in the highest
risk group which included those with diabetes with long lesions andsmall arteries (ICER: 18,826 US$/QALY) [32].

Discussion: measures to improve the health economics of PCI
In order to improve the health economics of interventional procedures, it is imperative that the populations under consideration fortreatment be directed toward optimization of cases. In other words,
the process of selecting cases for which additional usefulness can be expected (including informed consent) is as important as the process oftreatment quality control (including treatment planning), in improving
the performance (cost-effectiveness) of interventional procedures. In
this way, it is desired that diagnosis, treatment as well as support

Table 2
Cost-effectiveness comparison of percutaneous coronary intervention and medical therapy. Cost-effectiveness results for a cohort of 1000 patients.
Source: Reference [29].

Other cost-effectiveness examples
We present a report on the cost-effectiveness analysis of PCI in termsof catheter approach and stent type. First, a database (Victorian Cardiac
Outcomes Registry) study comparing the economics of transradial withtransfemoral access PCI found that the radial access group had
improved patient outcomes (mortality rate: 19 fewer per 1000) and

Treatment

Total costs

Total
QALYs

Cost
difference

QALY
difference

ICER

Placebo
PCI£410,405£1,995,418

796.092
813.661£1,585,012

17.569£90218a

ICER, incremental cost-effectiveness ratio; PCI, percutaneous coronary intervention;
QALYs, quality-adjusted life-years.
a
ICER calculated prior to rounding.
5

T. Takura, I. Komuro and M. Ono

Journal of Cardiology xxx (xxxx) xxx

Therefore, we will attempt to organize trends in the treatment selection related to evaluation of examinations and diagnoses, with a focus
on the ﬁeld of chronic coronary syndrome (CCS). The COURAGE trial
found that PCI did not reduce mortality/AMI when compared to optimal
medical therapy (OMT) in patients with stable coronary artery disease,
thereby questioning the efﬁcacy of revascularization [41,42]. The
ORBITA trial also reported that PCI did not improve exercise time ascompared to a placebo procedure in patients with stable angina pectorisreceiving OMT [29,43]. On the other hand, the FAME 2 trial showed thatfractional ﬂow reserve-guided PCI reduced events as compared to drug
therapy alone in patients with stable coronary artery disease [44,45].
Against this background, from 2018, the diagnosis of functional ischemia has become a mandatory requirement for medical fee calculationin Japan as well. Recently, the ISCHEMIA trial, which compared early invasive treatment with conservative treatment strategies managed withpharmacotherapy in patients with moderate or greater ischemia, foundthat invasive treatment strategies were associated with cardiovasculardeath, MI, hospitalization for unstable angina/heart failure, andpostcardiac arrest composite events [45,46]. From the above, it is predicted that a combination of patient selection and clinical intervention
will inﬂuence the cost-effectiveness of PCI. Therefore, we will present
reports from Japan on medical economic analysis of examinations anddiagnoses regarding PCI.
Firstly, we focus on a Japanese report that evaluated the medical economic value of myocardial ischemia assessment for CCS patients in thereal world [47]. This multicenter long-term longitudinal cohort study
applied medical big data (including defer and revascularization cases).
The analysis found that major adverse cardiovascular events as well as
the medical costs and cost-effectiveness of the myocardial ischemia assessment group (including cases with combined coronary computed tomography angiography) outperformed the anatomic assessment group(CEA: 2431 US$/LY vs. 2902 US$/LY, p = 0.043) (Table 4). The numberof coronary stents placed during PCI intervention was signiﬁcantly
lower in the myocardial ischemia assessment group (1.91 vs. 1.17,
p = 0.001). This study also revealed the social importance of medical
treatment selection based on information about myocardial ischemia.
Secondly, we look at a study that aimed to evaluate the costeffectiveness of follow-up invasive coronary angiography (FUICA)
after PCI [48]. This retrospective long-term longitudinal cohort study
showed that the cumulative three-year incidence of the primary endpoint was 5.3 % in the angiographic follow-up group and 4.7 % in theclinical follow-up alone group (hazard ratio: 1.02; p = 0.98). The total
incremental cost at the three-year endpoint in the angiographic
follow-up group was $ 1873 higher than that in the clinical follow-up

Table 3Cost-effectiveness comparison of transradial access percutaneous coronary intervention(PCI) and transfemoral access PCI. Results of the base-case analyses.
Source: Reference [34].
Parameter

Treatment arm

Difference

TRA-PCI

TFA-PCI

127.6
13.1
29.8

133.1
20.8
42.5

−5.5
−7.7
−12.7

Clinical effectiveness parameters (discounted)
Total life years
1877.10
Total QALYs
1488.90

1863.701477.10

13.4
11.9

Cost parameters (discounted)
Index PCI costs$14,141,798
Acute event costs$1,598,621
Annual disease costs$10,804,724
Total costs$26,545,143$14,141,798$1,729,784$10,724,865$26,596,448$0−$131,163$79,859−$51,305

Cost-effectiveness parameters
Cost per YoLS–
Cost per QALY gained–––−$3822−$4325

Key acute clinical events
Non-fatal CVD
Bleeding
Fatal CVD

CVD, cardiovascular disease; QALY, quality-adjusted life year; PCI, percutaneous coronary
intervention; TFA-PCI, transfemoral access-percutaneous coronary intervention; TRA-PCI,
transradial access-percutaneous coronary intervention; YoLS, year of life saved. All costs
are presented in 2021 Australian dollars (AU $).

programs such as follow-up (prevention of recurrence and aggravation), are organically linked in order to improve the medical economicsof health programs and medical technology in a certain group. This concept is positioned in the clinical value chain as it synergistically enhances the individual value of diagnosis and treatment. For example,
in a condition such as heart failure that repeats acute and chronic
phases, early examination/diagnosis and treatment strategies may affect not only the prognosis of the target treatment cycle, but also the
medical economics in the patient's journey (as shown in the lifetime
analysis illustrated in the earlier section). Looking at these from a
broad perspective, it is understood that they overlap with the conceptsof Appropriate Use Criteria (AUC) and Universal Health Coverage(UHC), which have been the recent focus of attention in relation
to the Sustainable Development Goals (SDGs) [39,40]. In order to further improve the social signiﬁcance of PCI in the future, it is necessary
to aim for harmony between clinical practice and economics aswell as to promote treatment strategies from the above-mentioned
perspective.

Table 4
Health economics-based veriﬁcation of functional myocardial ischemia evaluation of stable coronary artery disease in Japan: a long-term longitudinal study using propensity scorematching. Comparison of the medical costs, life years, and cost-effective analysis in the functional group and the anatomical group (by category).
Source: Reference [47].
A: Over all

Life years (LYs, years)
Total medical costs (US$)
Hospitalization costs (US$)[Details]
Medical care (US$)
Medication (US$)
Special treatment materials (US$)
Outpatient costs (US$)[Details]
Medical care (US$)
Medication (US$)
CEA (US$/LY)

B: Non-invasive examination

Anatomical group(n = 699)

Functional group(n = 699)

P value

Mean ± SD

Mean ± SD

2.663 ± 0.560
7038 ± 11,397
4430 ± 10,644

2.666 ± 0.543
6248 ± 8653
3105 ± 7588

0.916
0.144
0.007

2141 ± 5768
287 ± 1186
2002 ± 5392
2608 ± 2905

1705 ± 4472
339 ± 883
1061 ± 3897
3143 ± 3205

1080 ± 817
1528 ± 2418
2902 ± 5115

1290 ± 946
1853 ± 2659
2431 ± 3433

C: Invasive examination

CTA group(n = 402)

SPECT group(n = 402)

P value

CAG group(n = 261)

FFR/SPECT group(n = 261)

Mean ± SD

Mean ± SD

2.619 ± 0.562
5149 ± 8535
2592 ± 7791

2.675 ± 0.525
4059 ± 5957
1197 ± 4964

0.146
0.036
0.003

0.115
0.356
<0.0010.001

961 ± 3103
130 ± 1164
1501 ± 4648
2557 ± 2508

602 ± 2723
112 ± 495
483 ± 2354
2862 ± 2842

<0.0010.017
0.043

1086 ± 794
1471 ± 2073
2120 ± 3750

1252 ± 846
1610 ± 2371
1551 ± 2188

P value

Mean ± SD

Mean ± SD

2.695 ± 0.544
13,587 ± 16,371
10,350 ± 16,157

2.652 ± 0.561
9485 ± 11,190
6228 ± 10,024

0.383
0.001
0.001

0.082
0.777
<0.0010.1076003 ± 9387
833 ± 1935
3514 ± 6648
3237 ± 3319

3488 ± 6057
688 ± 1241
2052 ± 5550
3257 ± 3310

<0.001
0.309
0.007
0.946

0.004
0.376
0.009

1143 ± 859
2094 ± 2839
5404 ± 7183

1229 ± 866
2028 ± 2856
3701 ± 4511

0.254
0.789
0.001

CTA, coronary computed tomography angiography; SPECT, cardiac single-photon emission computed tomography; CAG, coronary angiography; FFR, coronary fractional ﬂow reserve; SD,
standard deviation; CEA, cost-effective analysis.
6T. Takura, I. Komuro and M. Ono

Journal of Cardiology xxx (xxxx) xxx[4] Takura T. Current trends in medical economics in the circulatory ﬁeld - socioeconomics background and research issue. Circ Rep 2019;1:342–6. https://doi.org/10.
1253/circrep.CR-19-0031.
[5] The Japanese Circulation Society. Cardiovascular disease medical treatment survey
report-JROAD (The Japanese Registry Of All cardiac and vascular Diseases). https://www.j-circ.or.jp/jittai_chosa/media/jittai_chosa2019web.pdf; 2020. [Accessed 8
January 2022].
[6] Sülz S, Wagenaar H, van de Klundert J. Have dutch hospitals saved lives and reduced
costs? A longitudinal patient-level analysis over the years 2013–2017. Health Econ
2021;30:2399–408. https://doi.org/10.1002/hec.4391.
[7] Organization for Economic Co-operation and Development. OECD health statistics
2021. https://www.oecd.org/health/; 2021. [Accessed 8 January 2022].
[8] World Bank. Purchasing power parities and the size of world economies - resultsfrom the 2017 International Comparison Program. Washington, DC: World Bank;
2020.https://openknowledge.worldbank.org/handle/10986/33623.
[9] Inohara T, Kohsaka S, Spertus JA, Masoudi FA, Rumsfeld JS, Kennedy KF, et al. Comparative trends in percutaneous coronary intervention in Japan and the UnitedStates, 2013 to 2017. J Am Coll Cardiol 2020;76:1328–40. https://doi.org/10.1016/j.
jacc.2020.07.037.
[10] Iijima K, Arai H, Akishita M, Endo T, Ogasawara K, Kashihara N, et al. Toward the development of a vibrant, super-aged society: the future of medicine and society inJapan. Geriatr Gerontol Int 2021;21:601–13. https://doi.org/10.1111/ggi.14201.
[11] Takura T. An evaluation of clinical economics and cases of cost-effectiveness. Intern
Med 2018;57:1191–200. https://doi.org/10.2169/internalmedicine.9835-17.
[12] Miyamoto JM, Eraker SA. Parameter estimates for a QALY utility model. Med Decis
Mak 1985;5:191–213. https://doi.org/10.1177/0272989X8500500208.
[13] Anderson JL, Heidenreich PA, Barnett PG, Creager MA, Fonarow GC, Gibbons RJ, et al. ACC/
AHA statement on cost/value methodology in clinical practice guidelines and performance measures: a report of the american College of Cardiology/American Heart Association task force on performance measures and task force on practice guidelines.
Circulation 2014;129:2329–45. https://doi.org/10.1161/CIR.0000000000000042.
[14] Pliskin JS, Stason WB, Weinstein MC, Johnson RA, Cohn PF, McEnany MT, et al. Coronary
artery bypass graft surgery: clinical decision making and cost-effectiveness analysis. Med
Decis Mak 1981;1:10–28. https://doi.org/10.1177/0272989X8100100104.
[15] Takura T, Yokoi H, Nakata T. Health economic evaluation and various diagnostic imaging. Nuc Cardiol 2021;24:29–31. https://doi.org/10.14951/jsnc.24-002.
[16] Ministry of Health Japan Labor and Welfare. About the immediate operation of thecost-effectiveness evaluation system-Central Social Insurance Medical Council:
Total No. 9. https://www.mhlw.go.jp/content/12404000/000736552.pdf; 2022.
[Accessed 8 January 2022].
[17] Shiroiwa T, Fukuda T, Ikeda S, Takura T, Moriwaki K. Development of an ofﬁcial
guideline for the economic evaluation of drugs/medical devices in Japan. Value
Health 2017;20:372–8. https://doi.org/10.1016/j.jval.2016.08.726.
[18] Howick J, Chalmers I, Glasziou P, Greenhalgh T, Heneghan C, Liberati A. The 2011 Oxford CEBM evidence levels of evidence (introductory document). Oxford: Oxford
Centre for Evidence Based Medicine; 2011. http://www.cebm.net/index.aspx?o=5653. [Accessed 1 August 2022].
[19] Schoenenberger AW, Radovanovic D, Windecker S, Iglesias JF, Pedrazzini G, Stuck
AE, et al. Temporal trends in the treatment and outcomes of elderly patients withacute coronary syndrome. Eur Heart J 2016;37:1304–11.
[20] Hansen MC, Wang TY, Chen AY, Chiswell K, Bhatt DL, Enriquez JR, et al. Contemporary patterns of early coronary angiography use in patients with non-ST-segment elevation myocardial infarction in the United States: insights from the National
Cardiovascular Data Registry Acute Coronary Treatment and intervention outcomes
network registry. JACC Cardiovasc Interv 2018;11:369–80. https://doi.org/10.1016/j.
jcin.2017.12.016.
[21] Forné C, Subirana I, Blanch J, Ferrieres J, Azevedo A, Meisinger C, et al. A cost-utility
analysis of increasing percutaneous coronary intervention use in elderly patientswith acute coronary syndromes in six european countries. Eur J Prev Cardiol 2021;
28:408–17. https://doi.org/10.1177/2047487320942644.
[22] Girasis C, Farooq V, Diletti R, Muramatsu T, Bourantas CV, Onuma Y, et al. Impact of
3-dimensional bifurcation angle on 5-year outcome of patients after percutaneous
coronary intervention for left main coronary artery disease: a substudy of the
SYNTAX trial (synergy between percutaneous coronary intervention with taxus
and cardiac surgery). JACC Cardiovasc Interv 2013;6:1250–60. https://doi.org/10.
1016/j.jcin.2013.08.009.
[23] Osnabrugge RL, Magnuson EA, Serruys PW, Campos CM, Wang K, van Klaveren D,
et al. Cost-effectiveness of percutaneous coronary intervention versus bypass surgery from a dutch perspective. Heart 2015;101:1980–8. https://doi.org/10.1136/
heartjnl-2015-307578.
[24] Cohen DJ, Osnabrugge RL, Magnuson EA, Wang K, Li H, Chinnakondepalli K, et al.
Cost-effectiveness of percutaneous coronary intervention with drug-eluting stents
versus bypass surgery for patients with 3-vessel or left main coronary artery disease: ﬁnal results from the synergy between percutaneous coronary intervention
with TAXUS and cardiac surgery (SYNTAX) trial. Circulation 2014;130:1146–57.
https://doi.org/10.1161/CIRCULATIONAHA.114.009985.
[25] Magnuson EA, Chinnakondepalli K, Vilain K, Serruys PW, Sabik JF, Kappetein AP,
et al. Cost-effectiveness of percutaneous coronary intervention versus bypass surgery for patients with left main disease: results from the EXCEL trial. Circ Cardiovasc
Interv 2022;15:e011981. https://doi.org/10.1161/CIRCINTERVENTIONS.122.011981.
[26] Ariyaratne TV, Yap CH, Ademi Z, Rosenfeldt F, Duffy SJ, Billah B, et al. A systematic
review of cost-effectiveness of percutaneous coronary intervention vs. Surgery forthe treatment of multivessel coronary artery disease in the drug-eluting stent era.
Eur Heart J Qual Care Clin Outcomes 2016;2:261–70. https://doi.org/10.1093/
ehjqcco/qcw007.

alone group (US$ 8947 vs. US$ 7073; p ≤ 0.001). FUICA increased costs
while not improving clinical beneﬁts. As a result, FUICA was not economically more attractive than clinical follow-up alone. It should be
noted that these studies have some limitations in study design anddata type, as well as a degree of uncertainty in the study results.
Summary: as conclusion
As a result of investigating the current cost-effectiveness level of PCI,
the following ﬁndings were clariﬁed. The macro medical economics of
AMI treatment, which is the main target of PCI, was generally at an average level compared to other countries, but there is room for further
improvement in Japan's performance. Appropriate medical intervention
is essential for this improvement approach, as is the appropriate
selection of cost-effective medical technology. The standalone costeffectiveness evaluation of PCI tends to be relatively high among lifesaving interventions for ACS patients. Revascularization in a population
with multivessel coronary artery disease showed that CABG tended tobe more cost-effective than PCI in the long-term setting. On the other
hand, PCI has been suggested to be more cost-effective in patientswith SYNTAX Score ≤22 or left main coronary artery disease. A costeffectiveness report for stable angina pectoris patients did not support
PCI performance over medical therapy. In addition, some reports showing the medical economic superiority of myocardial ischemia evaluation
and IVUS guidance during PCI have predicted that active selection willcontribute to the improvement of the overall cost-effectiveness of PCI.
In order to further improve the social signiﬁcance (value) of PCI in the
future, it is necessary to aim for harmony between clinical practiceand health economics.
Funding
This research received no grant from any funding agency in the public,commercial, or not-for-proﬁt sectors.
Disclosures
Dr. Tomoyuki Takura, who is endowed by Chugai PharmaceuticalCo., Ltd., received grants from Nihon Medi-Physics Co., Ltd. and Fujiﬁlm
Toyama Chemical Co.
Data availability
The deidentiﬁed participant data will not be shared because the data
presented in this review paper were all cited.
Declaration of competing interest
There are no conﬂicts of interest to declare.
Acknowledgments
The authors would like to thank Dr. Tomoaki Nakata for contributing
to this paper.
References[1] Sasaki T, Izawa M, Okada Y. Current trends in health insurance systems: OECD countries vs Japan. Neurol Med Chir 2015;55:267–75. https://doi.org/10.2176/nmc.ra.
2014-0317.
[2] Ottolini FL, Buggio L, Somigliana E, Vercellini P. The complex interface between
economy and healthcare: an introductory overview for clinicians. Eur J Intern Med
2016;36:1–6. https://doi.org/10.1016/j.ejim.2016.07.030.
[3] Takura T. Socio-economic considerations of universal hea. lth coverage: focus on theconcept of health care value and medical treatment price. In: Tavares AI, editor.
Health insurance. London: Intech Open; 2022. https://doi.org/10.5772/intechopen.
104798. ISBN 978-1-80355-871-4. In press.
7

T. Takura, I. Komuro and M. Ono

Journal of Cardiology xxx (xxxx) xxx[38] Lee VW, Cheng FW, Choi AY, Fong ST, Yu CM, Yan BP. Clinical, humanistic, and economic outcomes between drug-eluting stent (DES) and bare metal stent (BMS): 18month follow-up study. J Med Econ 2017;20:239–45. https://doi.org/10.1080/
13696998.2016.1248971.
[39] Klein LW, Tamis-Holland J, Kirtane AJ, Anderson HV, Cigarroa J, Duffy PL, et al. The
appropriate use criteria: improvements for its integration into real world clinicalpractice. Catheter Cardiovasc Interv 2021;98:1349–57. https://doi.org/10.1002/ccd.
29784.
[40] Takura T, Miura H. Socioeconomic determinants of universal health coverage in theasian region. Int J Environ Res Public Health 2022;19:2376. https://doi.org/10.3390/
ijerph19042376.
[41] Sedlis SP, Hartigan PM, Teo KK, Maron DJ, Spertus JA, Mancini GB, et al. Effect of PCI
on long-term survival in patients with stable ischemic heart disease. N Engl J Med
2015;373:1937–46. https://doi.org/10.1056/NEJMoa1505532.
[42] Saito Y, Nishi T, Saito K, Kitahara H, Kawase Y, Matsuo H, et al. Clinical implications
and debates on the international study of comparative health effectiveness withmedical and invasive approaches trial. Cardiol Rev 2022;30:234–40. https://doi.
org/10.1097/CRD.0000000000000389.
[43] Al-Lamee R, Thompson D, Dehbi HM, Sen S, Tang K, Davies J, et al. Percutaneous coronary intervention in stable angina (ORBITA): a double-blind, randomized controlled trial. Lancet 2018;391:31–40. https://doi.org/10.1016/S0140-6736(17)32714-9.
[44] Xaplanteris P, Fournier S, Pijls NHJ, Fearon WF, Barbato E, Tonino PAL, et al. Five-year
outcomes with PCI guided by fractional ﬂow reserve. N Engl J Med 2018;379:250–9.
https://doi.org/10.1056/NEJMoa1803538.
[45] Brown DL. Optimal medical therapy as ﬁrst-line therapy for chronic coronary syndromes: lessons from COURAGE, BARI 2D, FAME 2, and ISCHEMIA. Cardiovasc
Drugs Ther 2021. https://doi.org/10.1007/s10557-021-07289-6. In press.
[46] Maron DJ, Hochman JS, Reynolds HR, Bangalore S, O'Brien SM, Boden WE, et al. Initial
invasive or conservative strategy for stable coronary disease. N Engl J Med 2020;382:
1395–407. https://doi.org/10.1056/NEJMoa1915922.
[47] Takura T, Yokoi H, Tanaka N, Matsumoto N, Yoshida E, Nakata T, et al. Healtheconomics-based veriﬁcation of functional myocardial ischemia evaluation of stablecoronary artery disease in Japan: a long-term longitudinal study using propensity
score matching. J Nucl Cardiol 2022;29:1356–69. https://doi.org/10.1007/s12350020-02502-9.
[48] Shiina T, Goto-Hirano K, Takura T, Daida H. Cost-effectiveness of follow-up invasivecoronary angiography after percutaneous coronary stenting: a real-world observational cohort study in Japan. BMJ Open 2022;12:e061617. https://doi.org/10.1136/
bmjopen-2022-061617.

[27] Robles-Zurita JA, Briggs A, Rana D, Quayyum Z, Oldroyd KG, Zeymer U, et al. Economic evaluation of culprit lesion only PCI vs. Immediate multivessel PCI in acute
myocardial infarction complicated by cardiogenic shock: the CULPRIT-SHOCK trial.
Eur J Health Econ 2020;21:1197–209. https://doi.org/10.1007/s10198-020-01235-3.
[28] El-Hayek GE, Gershlick AH, Hong MK, Casso Dominguez A, Banning A, Afshar AE, et al.
Meta-analysis of randomized controlled trials comparing multivessel versus culpritonly revascularization for patients with ST-segment elevation myocardial infarction
and multivessel disease undergoing primary percutaneous coronary intervention. Am J
Cardiol 2015;115:1481–6. https://doi.org/10.1016/j.amjcard.2015.02.046.
[29] McCreanor V, Nowbar A, Rajkumar C, Barnett AG, Francis D, Graves N, et al. Costeffectiveness analysis of percutaneous coronary intervention for single-vessel coronary artery disease: an economic evaluation of the ORBITA trial. BMJ Open 2021;11:
e044054. https://doi.org/10.1136/bmjopen-2020-044054.
[30] Kodera S, Morita H, Kiyosue A, Ando J, Komuro I. Cost-effectiveness of percutaneous
coronary intervention compared with medical therapy for ischemic heart disease inJapan. Circ J 2019;83:1498–505. https://doi.org/10.1253/circj.CJ-19-0148.
[31] Takura T, Tachibana K, Isshiki T, Sumitsuji S, Kuroda T, Mizote I, et al. Preliminary report on a cost-utility analysis of revascularization by percutaneous coronary intervention for ischemic heart disease. Cardiovasc Interv Ther 2017;32:127–36.
https://doi.org/10.1007/s12928-016-0401-5.
[32] Wijeysundera HC, Tomlinson G, Ko DT, Dzavik V, Krahn MD. Medical therapy v. PCI
in stable coronary artery disease: a cost-effectiveness analysis. Med Decis Mak 2013;33:891–905. https://doi.org/10.1177/0272989X13497262.
[33] Lee P, Brennan A, Dinh D, Stub D, Lefkovits J, Reid CM, et al. The cost-effectiveness ofradial access percutaneous coronary intervention: a propensity-score matched analysis of victorian data. Clin Cardiol 2022;45:435–46. https://doi.org/10.1002/clc.
23798.
[34] Lee P, Liew D, Brennan A, Stub D, Lefkovits J, Reid CM, et al. Cost-effectiveness of radial access percutaneous coronary intervention in acute coronary syndrome. Am J
Cardiol 2021;156:44–51. https://doi.org/10.1016/j.amjcard.2021.06.034.
[35] Cheng HM, Chiou LJ, Chen TC, Sung SH, Chen CH, Lang HC. Real-world costeffectiveness of drug-eluting stents vs. Bare-metal stents for coronary heartdisease-a ﬁve-year follow-up study. Health Policy 2019;123:229–34. https://doi.
org/10.1016/j.healthpol.2018.11.010.
[36] Zhou J, Liew D, Duffy SJ, Shaw J, Walton A, Chan W, et al. Intravascular ultrasoundversus angiography-guided drug-eluting stent implantation: a health economic
analysis. Circ Cardiovasc Qual Outcomes 2021;14:e006789. https://doi.org/10.
1161/CIRCOUTCOMES.120.006789.
[37] Hong SJ, Kim BK, Shin DH, Nam CM, Kim JS, Ko YG, et al. Effect of intravascularultrasound-guided vs angiography-guided everolimus-eluting stent implantation:
the IVUS-XPL randomized clinical trial. JAMA 2015;314:2155–63. https://doi.org/
10.1001/jama.2015.15454.

8