Cost-Effectiveness of Fractional Flow Reserve–Guided Treatment for Acute Myocardial Infarction and Multivessel Disease
Authors: David Hong, Seung Hun Lee, Jin Lee, Hankil Lee, Doosup Shin, Hyun Kuk Kim, Keun Ho Park, Eun Ho Choo, Chan Joon Kim, Min Chul Kim, Young Joon Hong, Myung Ho Jeong, Sung Gyun Ahn, Joon-Hyung Doh, Sang Yeub Lee, Sang Don Park, Hyun-Jong Lee, Min Gyu Kang, Jin-Sin Koh, Yun-Kyeong Cho, Chang-Wook Nam, Ki Hong Choi, Taek Kyu Park, Jeong Hoon Yang, Young Bin Song, Seung-Hyuk Choi, Hyeon-Cheol Gwon, Eliseo Guallar, Juhee Cho, Joo-Yong Hahn, Danbee Kang, Joo Myung Lee
Journal: JAMA Network Open (2024)

Importance Complete revascularization by non–infarct-related artery (IRA) percutaneous coronary intervention (PCI) in patients with acute myocardial infarction is standard practice to improve patient prognosis. However, it is unclear whether a fractional flow reserve (FFR)–guided or angiography-guided treatment strategy for non-IRA PCI would be more cost-effective. Objective To evaluate the cost-effectiveness of FFR-guided compared with angiography-guided PCI in patients with acute myocardial infarction and multivessel disease. Design, Setting, and Participants In this prespecified cost-effectiveness analysis of the FRAME-AMI randomized clinical trial, patients were randomly allocated to either FFR-guided or angiography-guided PCI for non-IRA lesions between August 19, 2016, and December 24, 2020. Patients were aged 19 years or older, had ST-segment elevation myocardial infarction (STEMI) or non-STEMI and underwent successful primary or urgent PCI, and had at least 1 non-IRA lesion (diameter stenosis &amp;amp;gt;50% in a major epicardial coronary artery or major side branch with a vessel diameter of ≥2.0 mm). Data analysis was performed on August 27, 2023. Intervention Fractional flow reserve–guided vs angiography-guided PCI for non-IRA lesions. Main Outcomes and Measures The model simulated death, myocardial infarction, and repeat revascularization. Future medical costs and benefits were discounted by 4.5% per year. The main outcomes were quality-adjusted life-years (QALYs), direct medical costs, incremental cost-effectiveness ratio (ICER), and incremental net monetary benefit (INB) of FFR-guided PCI compared with angiography-guided PCI. State-transition Markov models were applied to the Korean, US, and European health care systems using medical cost (presented in US dollars), utilities data, and transition probabilities from meta-analysis of previous trials. Results The FRAME-AMI trial randomized 562 patients, with a mean (SD) age of 63.3 (11.4) years. Most patients were men (474 [84.3%]). Fractional flow reserve–guided PCI increased QALYs by 0.06 compared with angiography-guided PCI. The total cumulative cost per patient was estimated as $1208 less for FFR-guided compared with angiography-guided PCI. The ICER was −$19 484 and the INB was $3378, indicating that FFR-guided PCI was more cost-effective for patients with acute myocardial infarction and multivessel disease. Probabilistic sensitivity analysis showed consistent results and the likelihood iteration of cost-effectiveness in FFR-guided PCI was 97%. When transition probabilities from the pairwise meta-analysis of the FLOWER-MI and FRAME-AMI trials were used, FFR-guided PCI was more cost-effective than angiography-guided PCI in the Korean, US, and European health care systems, with an INB of $3910, $8557, and $2210, respectively. In probabilistic sensitivity analysis, the likelihood iteration of cost-effectiveness with FFR-guided PCI was 85%, 82%, and 31% for the Korean, US, and European health care systems, respectively. Conclusions and Relevance This cost-effectiveness analysis suggests that FFR-guided PCI for non-IRA lesions saved medical costs and increased quality of life better than angiography-guided PCI for patients with acute myocardial infarction and multivessel disease. Fractional flow reserve–guided PCI should be considered in determining the treatment strategy for non-IRA stenoses in these patients. Trial Registration ClinicalTrials.gov Identifier: NCT02715518