Implementing a CYP2C19-guided approach for prescribing dual antiplatelet therapy in acute coronary syndrome for patients undergoing percutaneous coronary intervention: a cost-effectiveness analysis
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Background Prescribing guidelines recommend prasugrel or ticagrelor with aspirin as dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS), with clopidogrel reserved for people at high bleeding risk or with contraindications. We evaluated the cost-effectiveness of a point-of-care CYP2C19 genetic test to guide prescribing of DAPT compared with current prescribing practice in the NHS in England (NHS). Methods We designed a hybrid decision-tree and state transition Markov model (40-year horizon) to calculate the costs and Quality-Adjusted Life-Years (QALYs) of CYP2C19-guided DAPT compared with current prescribing for two post-PCI populations: ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction or unstable angina (UA/NSTEMI). In CYP2C19-guided DAPT, LoF carriers were prescribed prasugrel or ticagrelor; non-LoF carriers prescribed clopidogrel. Costs (£, 2024/25 prices, NHS and Social Services), event rates, and utility values were sourced from published data. Sensitivity analyses measured uncertainty in the analysis results. The model was built in R (available on GitHub). Results CYP2C19-guided DAPT generated an additional 0.0439 QALYs at an additional cost of £25 for STEMI, giving an incremental cost-effectiveness ratio (ICER) of £569 per QALY. In UA/NSTEMI, CYP2C19-guided DAPT generated an additional 0.0358 QALYs at an additional cost of £83, giving an ICER of £2,318 per QALY. At a cost-effectiveness threshold of £20,000 per QALY, CYP2C19-guided DAPT had a probability of being cost-effective of 87.6% in the STEMI population and 94.3% in the UA/NSTEMI population. Conclusions CYP2C19-guided DAPT was a cost-effective use of the NHS budget when compared with current prescribing practice for both STEMI and UA/NSTEMI populations.
