Cost and Effectiveness Analysis of Rate versus Rhythm Control of Atrial Fibrillation in Patients with Heart Failure

Background. Coexistence of atrial fibrillation (AF) and heart failure (HF) has been shown to produce a worse prognosis than either condition alone. Rate and rhythm control are two common treatment options in the management of AF; however, the relative cost effectiveness of these options in this population is not known. Objective. To compare costs and health outcomes in rate versus rhythm control of AF in HF. Methods. A Markov model was created to calculate all the costs and effects of rate and rhythm control strategies. The simulation cohort starting age was 65 with a diagnosis of AF and HF. Costs were measured in 2008 US dollars and clinical outcomes in quality-adjusted life-years, taking the third-party payer perspective. Economic outcomes of interest were drug acquisition, AF and HF hospitalization, and severe side effect costs. Costs and transition probabilities were obtained from the most rigorous studies available (pre-defined criteria) identified in MEDLINE and EMBASE searches and references of published manuscripts. Inpatient costs were obtained from the Healthcare Cost and Utilization Project database. A probabilistic sensitivity analysis was also conducted. Results. In the base-case analysis, the incremental life expectancy per patient of rhythm versus rate control as initial treatment was -0.154 quality-adjusted life years (2.827 versus 2.982), while the incremental life time cost was $6,920 ($29,589 versus $22,669 per patient per year). The same results were observed in the probabilistic sensitivity analysis. Conclusion. Based on this cost-effectiveness analysis, rate control should be the initial treatment of AF in this population. Grant. Not funded