Cost-effectiveness of Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention in Severe Ischemic Cardiomyopathy

• This study presents the first cost-effectiveness analysis comparing coronary artery bypass grafting + optimal medical therapy (CABG+OMT) versus percutaneous coronary intervention + optimal medical therapy (PCI+OMT) strategies in patients with severe ischemic cardiomyopathy, addressing a significant knowledge gap. • Despite being more invasive and having higher initial costs, CABG+OMT yields superior health outcomes and is economically favorable compared to the PCI+OMT strategy. • This study identifies CABG+OMT as the most cost-effective strategy over PCI+OMT in severe ischemic cardiomyopathy, thereby aiding decision-making for physicians and policymakers. Revascularization through coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) as an add-on therapy to optimal medical therapy (OMT) is routinely used in patients with severe ischemic cardiomyopathy (ICM) with left ventricular ejection fraction (LVEF) ≤ 35% to improve cardiovascular outcomes with limited available data about their relative costs and efficacies. We performed a cost-effectiveness analysis to illustrate the most economically favorable strategy in this population. A Markov model simulated a cohort with severe ICM (EF ≤ 35%) and evaluated strategies of CABG+OMT, PCI+OMT and OMT alone. Model inputs were obtained from STICH and REVIVED clinical trials and their subsequent cost-effectiveness analyses. Cohorts were followed monthly, with mortality and major adverse cardiac events (MACE; a composite of heart failure hospitalization, myocardial infarction, revascularization and arrythmias) modeled as lifetime disutilities, taking the US health system perspective, and discounting 3% per year over lifetime horizon. Outcome measures were lifetime medical costs (2019 US$), quality-adjusted-life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). OMT alone was the least costly strategy at $107,780 and yielded 5.29 QALYs. PCI+OMT yielded 5.50 QALYs and cost $124,295, while the CABG+OMT strategy resulted in 6.04 QALYs and cost $154,965 with an ICER of $62,786 per QALY gained. Thus, CABG+OMT was preferred at a $100,000/QALY gained threshold, a commonly cited US benchmark. In a probabilistic sensitivity analysis, CABG+OMT was the preferred strategy in 25%, 51% and 58% of the model iterations at $50,000, $100,000, and $150,000 per QALY gained willingness-to-pay (WTP) thresholds respectively. CABG+OMT is the most cost-effective strategy in patients with severe ICM as compared with PCI+OMT or OMT only strategies at current benchmarks for value in the United States.