Cost-Effectiveness of Percutaneous Coronary Intervention Compared With Medical Therapy for Ischemic Heart Disease in Japan

Abstract

Background: The cost-effectiveness of percutaneous coronary intervention (PCI) for ischemic heart disease is undetermined in Japan. The aim of this study was to analyze the cost-effectiveness of PCI compared with medical therapy for ST-elevation myocardial infarction (STEMI) and angina pectoris (AP) in Japan.

Methods and Results: We used Markov models for STEMI and AP to assess the costs and benefits associated with PCI or medical therapy from a health system perspective. We estimated the incremental cost-effectiveness ratio (ICER), expressed as quality-adjusted life-years (QALY), and ICER <¥5 m per QALY gained was judged to be cost-effective. The impact of PCI on cardiovascular events was based on previous publications. In STEMI patients, the ICER of PCI over medical treatment was ¥0.97 m per QALY gained. The cost-effectiveness probability of PCI was 99.9%. In AP patients, the ICER of fractional flow reserve (FFR)-guided PCI over medical treatment was ¥4.63 m per QALY gained. The cost-effectiveness probability of PCI was 50.4%. The ICER of FFR-guided PCI for asymptomatic patients was ¥23 m per QALY gained.

Conclusions: In STEMI patients, PCI was cost-effective compared with medical therapy. In AP patients, FFR-guided PCI for symptomatic patients could be cost-effective compared with medical therapy. FFR-guided PCI for asymptomatic patients with myocardial ischemia was not cost-effective.

Medical costs are rising secondary to population aging and advances in medical technology, and this has hindered national finance management in Japan. To efficiently use limited medical expenses, cost-effectiveness analysis is gaining attention in the medical field. Medical expenses for ischemic heart disease were as high as ¥743 bn in Japan in 2016 because there were 750,000 patients with ischemic heart disease and 71,000 patients who died of ischemic heart disease.¹ Percutaneous coronary intervention (PCI) is widely performed as a treatment for ischemic heart disease. The cost of individual PCI is as high as ¥1 m, and because >250,000 PCI are performed annually in Japan, it is essential to consider the cost-effectiveness of PCI for ischemic heart disease. In evaluating the cost-effectiveness of PCI for ischemic heart disease, it is important to distinguish ST-elevation myocardial infarction (STEMI) from angina pectoris (AP) because the effect of PCI in STEMI is different to that for AP. According to a meta-analysis, the effect of PCI in STEMI resulted in a 27% decrease in mortality, and the benefits have been established.² In contrast, the effect of PCI in AP is controversial. In the Fractional Flow Reserve versus Angiography for Multivessel Evaluation 2 (FAME 2) trial, a large randomized controlled trial evaluating patients with AP, cardiovascular events were significantly reduced in the fractional flow reserve (FFR)-guided PCI group.^3,4 The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial, however, a large randomized controlled trial evaluating patients with AP, showed no difference in cardiovascular events between PCI and medical therapy.⁵ The initial PCI method for STEMI differs to that for AP. That is, primary PCI is performed for STEMI patients while FFR-guided PCI is performed for AP patients. Consequently, the cost-effectiveness of PCI should be evaluated separately for STEMI and AP. Variable results have been reported for the cost-effectiveness of PCI over medical treatment for STEMI and AP.^6–14 Many studies showed that PCI in STEMI was cost-effective compared with medical therapy,^6–9 and some studies reported that PCI for AP was cost-effective compared with medical therapy, whereas others reported PCI for AP was not cost-effective.^10–14 Cost-effectiveness needs to be evaluated by country because the incidence of cardiovascular events and the medical delivery systems vary from country to country. In Japan, the cost-effectiveness of PCI for ischemic disease has not been adequately studied. In this study, we examined the cost-effectiveness of PCI for ischemic heart disease (STEMI and AP) compared with medical therapy, in Japan.

Methods

We developed economic models to evaluate the cost-effectiveness of PCI and medical therapy for STEMI and AP. The models evaluated quality-adjusted life years (QALY) and costs of PCI and medical therapy over a 30-year time horizon from the Japanese health system perspective. Markov models were used to model the onset of cardiovascular events (myocardial infarction [MI], PCI, stroke, death) in Japanese patients. For the STEMI model, cardiovascular event rates in the PCI group and medical treatment group were estimated based on the Japan registry of acute Myocardial Infarction diagnosed by Universal dEfiniTion (J-MINUET) study and a meta-analysis.^2,15 The J-MINUET study is a large-registry study of acute MI (AMI) in Japan.¹⁵ For the AP model, cardiovascular event rates in the PCI group and medical treatment group were estimated based on the FAME 2 study and the Coronary Revascularization Demonstrating Outcome study in Kyoto (CREDO Kyoto) study.^3,4,16 The CREDO Kyoto study is a large-registry study of PCI in Japan.¹⁶ In the present study, primary outcomes were estimated as incremental cost-effectiveness ratio (ICER) per QALY gained. Based on previous studies, we set the cut-off of cost-effectiveness at ¥5 m per QALY gained in Japan.^17,18 Analyses were performed according to the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement and Japanese guidelines.^18,19

Model

Markov models with Monte Carlo simulations^8,9,13,20,21 were developed to estimate the efficacy and cost of PCI and medical treatment for STEMI and AP. The STEMI model started from the STEMI state, and was then transferred to old MI, PCI, stroke, and death based on the events (Figure 1A). The AP model started from the AP state, was transferred to AP, PCI, AMI, stroke, and death based on the events (Figure 1B). The models were used to estimate cardiovascular events and death, and the models had a monthly cycle.

Figure 1.

Markov model of the effects of percutaneous coronary intervention (PCI) on (A) ST-elevation myocardial infarction (STEMI) and (B) angina pectoris (AP). The model applies to each monthly cycle. Each month, patients could be moved in the direction of any arrow. AMI, acute myocardial infarction; OMI, old myocardial infarction.

Patients and Intervention

STEMI The target population for STEMI was based on the J-MINUET study. The average age of the target patients was 68 years; 77% of patients were men; diabetes mellitus was present in 35% of patients; and single-vessel disease was present in 58% of patients (Table 1).¹⁵ The percentage of patients admitted ≤12 h after onset was 89%. In the PCI group, the door-to-balloon time was ≤90 min. Patients in the medical therapy group received i.v. monteplase at 137,500–275,000 units/kg according to the Japanese guidelines.²²

Table 1. Patient Characteristics

	STEMI patients15		AP patients3,4,16
	PCI	Medical therapy	PCI	Medical therapy
Average age (years)	68	68	67	67
Male (%)	77	77	70	70
Hypertension (%)	63	63	69	69
Diabetes mellitus (%)	35	35	36	36
Dyslipidemia (%)	50	50	50	50
Killip class ≥2 (%)	26	26	–	–
CCS class ≥2 (%)	–	–	70	70
Single-vessel disease (%)	58	58	76	76

CCS, Canadian Cardiovascular Society; PCI, percutaneous coronary intervention; STEMI, ST elevation myocardial infarction.

AP Target patients with symptomatic AP underwent coronary angiography, and significant stenosis was confirmed on FFR, consistent with the FAME 2 study.^3,4 The average age of the target patients was 67 years; 70% were men; Canadian Cardiovascular Society class was ≥2 in 70% of patients; 36% had diabetes mellitus; and 76% had single-vessel disease (Table 1).^3,4,16 Optimal medical therapy was performed based on Japanese guidelines, in the medical therapy group.²³ PCI was performed for FFR-positive coronary stenosis in the FFR-guided PCI group.

Time Horizon

In this study, the time horizon for both models was set to 30 years. Because target patients for both models were in their late 60 s, we considered that a 30-year observation period was sufficient to estimate the cost-effectiveness of PCI. In the scenario analysis, we evaluated data for patients with an observation period of 5 years, 10 years, 20 years, and 40 years.

Mortality and Morbidity

Table 2 lists the mortality and morbidity for PCI and medical therapy in STEMI patients and AP patients. In the STEMI model, the mortality rate in the first month was 7.0% for PCI and 9.3% for medical treatment, based on meta-analysis and the J-MINUET study.^2,8,15 The new PCI rate in STEMI patients was 4.2% in the PCI group and 13% in the medical treatment group.^2,8,15 In the AP model, the annual mortality rate in the first 5 years was 1.0% for both FFR-guided PCI and medical treatment, based on the FAME 2 study.^3,4 The new PCI rate in the first year was 3% in the FFR-guided PCI group and 30% in the medical therapy group.^3,4

Table 2. Key Parameters Used in the Models

Parameter	STEMI patients			AP patients
	PCI	Medical therapy	Reference	PCI	Medical therapy	Reference
Event rate
New PCI	4.2%/first month, 3.7%/year	13%/first month, 9.1%/year	2,8,15	3%/year	1 year 30%, 2 years 10%, 3 years 3%	3,4
AMI	7.0%/first month, 1.5%/year	9.3%/first month, 1.9%/year	2,8,15	1.5%/year	2.4%/year	3,4
New stroke	0.9%/first month, 0.7%/year	2.0%/first month, 0.7/year	2,8,15	0.7%/year	0.5%/year	3,4
Death	7.0%/month, life table (mortality reduction 30%)	9.3%/month, life table	2,8,15, life table	1%/year, life table	1%/year, life table	3,4, life table
Cost
Stable angina cost	–	–	–	¥1,005,078/first month (670,000– 1,340,000)	¥495,600/year (460,000– 570,000)	26,27,29
New PCI cost	¥1,705,078/event (700,000– 270,000)	¥1,705,078/event (700,000– 270,000)	26,27,29	¥1,705,078/event (700,000– 270,000)	¥1,705,078/event (700,000– 270,000)	26,27,29
Post-PCI cost	–	–	–	¥495,600/year (460,000– 570,000)	¥495,600/year (460,000– 570,000)	26,27,29
AMI cost	¥2,156,290/event (1,950,000– 2,380,000)	¥1,453,200/event (1,310,000– 1,5900,00)	25,27–29	¥2,156,290/event (1,950,000– 2,380,000)	¥2,156,290/event (1,950,000– 2,380,000)	25,27–29
OMI cost	¥900,432/year (860,000– 940,000)	¥900,432/year (860,000– 940,000)	25,27–29	¥900,432/year (860,000– 940,000)	¥900,432/year (860,000– 940,000)	25,27–29
New stroke cost	¥1,699,225/event (1,600,000– 1,810,000)	¥1,699,225/event (1,600,000– 1,810,000)	24,25	¥1,699,225/event (1,600,000– 1,810,000)	¥1,699,225/event (1,600,000– 1,8100,00)	24,25
Post-stroke cost	¥318,387/year (263,000– 373,000)	¥318,387/year (263,000– 373,000)	24,25	¥318,387/year (263,000– 373,000)	¥318,387/year (263,000– 373,000)	24,25
Death cost	¥1,955,000/event (1,120,000– 2,790,000)	¥1,955,000/event (1,120,000– 2,790,000)	13	¥1,955,000/event (1,120,000– 2,790,000)	¥1,955,000/event (1,120,000– 2,790,000)	13
Utility
AP	–	–	–	0.84±0.1	0.84±0.1	12,14
New PCI	0.79±0.18	0.79±0.18	25,26	0.79±0.18	0.79±0.18	25,26
Post PCI	–	–	–	0.86±0.1	0.86±0.1	12,14
AMI	0.67±0.17	0.67±0.17	25,26	0.67±0.17	0.67±0.17	25,26
OMI	0.82±0.09	0.82±0.09	25,26	0.82±0.09	0.82±0.09	25,26
New stroke	0.33±0.23	0.33±0.23	24,26	0.33±0.23	0.33±0.23	24,26
Post stroke	0.52±0.19	0.52±0.19	24,26	0.52±0.19	0.52±0.19	24,26

AMI, acute myocardial infarction; AP, angina pectoris; OMI, old myocardial infarction. Other abbreviations as in Table 1.

Utility

We used QALY as an outcome measurement in this analysis and measured QALY based on the EuroQol 5 dimension (EQ-5D) questionnaire.^{12,14,24–26} Based on previous studies, we set quality of life (QOL) for STEMI and old MI at 0.67 and 0.82, respectively;^25,26 QOL for AP was set at 0.84.^12,14 Based on the FAME 2 study, we assumed that FFR-guided PCI in AP patients improved QOL by 0.02.^12,14 For FFR-guided PCI in AP patients, we conducted several scenario analyses for several situations: when QOL improvement was not observed at all; when QOL improvement lasted only 2 years; and when QOL improvement was >0.02 (improved QOL by 0.04). Based on previous studies, we set QOL for new stroke and prior stroke at 0.33 and 0.52, respectively.^24,26 All utility was discounted at 2% per year according to Japanese guidelines.¹⁸

Costs

Resources when considering the costs included initial intervention (e.g., drug acquisition costs, procedure costs, and hospital stay costs) and subsequent events, such as repeat revascularization, MI, or stroke. In this analysis, we did not include the costs of transportation, temporary leave from work, or family nursing care expenses. Referring to the previous literature on measured cost,^{13,24,25,27–30} the cost of primary PCI for STEMI was ¥2,156,290, and the cost of medical therapy for STEMI was ¥1,453,200.^25,27–29 In the AP analysis, the cost of AP was ¥495,600, and the cost of post-PCI care was ¥495,600.^26,27,29 We also performed a scenario analysis for situations when the annual post-PCI costs were ¥120,000 higher or ¥120,000 lower than the cost of AP. All costs were discounted by 2% per year according to Japanese guidelines.¹⁸

Scenario Analysis

We performed several scenario analyses to investigate the validity of the primary analyses. In the STEMI analysis, we analyzed the situation when the treatment effect of PCI was limited to only the acute phase, and not after discharge. We also analyzed the situation when the treatment effect of PCI was larger (mortality reduced by 61%).³¹ We also examined non-STEMI (NSTEMI) patients. In NSTEMI patients, the mortality reduction effect of PCI was assumed to be 17%.³² In the AP analysis, we studied FFR-positive asymptomatic patients with and without diabetes. We analyzed PCI for asymptomatic patients assuming no improvement in QOL. Based on a previous study, we hypothesized that coronary events would be doubled in diabetic patients.³³ We also examined the situation when PCI had no effect on the occurrence of cardiovascular events, based on the COURAGE trial.⁵

Sensitivity Analysis

We performed several sensitivity analyses to ensure the robustness of this research. The effect of uncertainty on all input parameters was statistically analyzed. The distribution of parameters (β distribution or gamma distribution) depended on the type of parameters. We estimated the range of parameters and performed 100,000 simulations. Based on previous reports, we set the cost-effective cut-off point at ¥5 m per QALY gained.¹⁷ A threshold value of ¥5 m per QALY gained was used to create a cost-effect tolerance curve to evaluate the cost-effectiveness of PCI. Analysis was performed using TreeAge Pro 2018 (TreeAge, Williamstown, MA, USA).

Results

The main results of the analysis are shown in Table 3. In STEMI patients, for the 30-year observation period, the costs of PCI and medical therapy were ¥15.6 m and ¥14.2 m, respectively; the effects were 10.9 QALY and 9.29 QALY, respectively; and the ICER of PCI over medical treatment was ¥0.97 m per QALY gained.

Table 3. Cost-Effectiveness of PCI

Arm	Cost mean, 95% confidence interval	QALY mean, 95% confidence interval	ICER / QALY gained
STEMI patients
PCI	¥15.6 m (8.13–26.4 m)	10.9 (7.98–14.2)	¥0.97 m
Medical therapy	¥14.2 m (7.44–23.7 m)	9.29 (6.86–12.1)
AP patients
PCI	¥10.2 m (7.64–14.6 m)	12.73 (9.76–16.19)	¥4.63 m
Medical therapy	¥9.76 m (7.44–13.6 m)	12.60 (10.37–15.10)

AP, angina pectoris; ICER, incremental cost-effectiveness ratio; QALY, quality-adjusted life-year. Other abbreviations as in Table 1.

In AP patients, for the 30-year observation period, the costs of FFR-guided PCI and medical therapy were ¥10.2 m and ¥9.76 m, respectively; effects were 12.7 QALY and 12.6 QALY, respectively; and the ICER of FFR-guided PCI over medical treatment was ¥4.63 m per QALY gained.

Scenario Analysis

The results of scenario analysis are shown in Table 4. For STEMI, the ICER of PCI over medical therapy was ¥2.80 m per QALY gained, assuming that the effect of PCI is present only in the acute phase. For NSTEMI, the ICER of PCI over medical therapy was ¥1.73 m per QALY gained. Even for patients aged 75 years, 80 years, and 85 years, ICER was <¥5 m per QALY gained.

Table 4. Scenario Analyses

PCI vs. medical therapy	ICER / QALY gained
STEMI patients
NSTEMI	¥1.73 m
PCI effect only in the acute phase	¥2.80 m
PCI mortality reduction increase	¥1.06 m
Starting age
75 years	¥1.09m
80 years	¥1.19m
85 years	¥1.27 m
Time horizon
5 years	¥2.02 m
10 years	¥0.93 m
20 years	¥0.86 m
40 years	¥0.96 m
AP patients
Asymptomatic (CCS class 0) without diabetes	¥23.0 m
Asymptomatic (CCS class 0) with diabetes	¥7.02 m
Follow-up PCI cost decrease by ¥120,000	¥0.46 m
Follow-up PCI cost increase by ¥120,000	¥13.0 m
COURAGE trial assumption (no CVD event reduction)	¥26.2 m
Two-fold QOL improvement for PCI (0.04)	¥1.98 m
QOL improvement for PCI lasting only 2 years	¥24.1 m
Starting age
75 years	¥5.86 m
80 years	¥7.02 m
85 years	¥8.69m
Time horizon
5 years	¥14.5 m
10 years	¥8.66 m
20 years	¥5.81 m
40 years	¥4.47 m

COURAGE, Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation; CVD, cardiovascular disease; NSTEMI, non-ST-elevation myocardial infarction; QOL, quality of life. Other abbreviations as in Tables 1,3.

For AP, the ICER for FFR-guided PCI over medical therapy was ¥23 m per QALY gained in asymptomatic patients (Canadian Cardiovascular Society class 0) without diabetes. The ICER for FFR-guided PCI was ¥7.0 m per QALY gained in asymptomatic patients with diabetes. The ICER for FFR-guided PCI was ¥0.46 m per QALY gained, assuming that the annual costs after PCI were ¥120,000 lower than the costs before PCI. In contrast, the ICER for FFR-guided PCI was ¥13 m per QALY gained, assuming that the annual costs after PCI were ¥120,000 higher than the costs before PCI. In the COURAGE trial scenario (no significant cardiovascular event reduction), the ICER for PCI was ¥26.2 m per QALY gained. The ICER for FFR-guided PCI was ¥24.1 m per QALY gained when assuming that the QOL improvement effect lasted only 2 years.

Probabilistic Sensitivity Analysis

The simulated cost-effectiveness of PCI is shown in Figure 2. For STEMI, the PCI group had better QALY and higher costs (Figure 2A). QALY improvement with PCI was considerably larger, and many points were distributed below the line of ¥5 m per QALY gained. For AP, the FFR-guided PCI group had slightly better QALY and slightly higher costs (Figure 2B). Many points were distributed almost evenly above and below the line for ICER ¥5 m per QALY gained. The cost-effectiveness acceptability curves for PCI over medical therapy are presented in Figure 3. With a cost-effectiveness threshold of ¥5 m per QALY gained, the cost-effectiveness probability of PCI over medical therapy was 99.9% in STEMI patients (Figure 3A). The cost-effectiveness of PCI over medical therapy was 50.4% in AP patients (Figure 3B).

Figure 2.

Cost-effectiveness plots for percutaneous coronary intervention over medical therapy in (A) ST-elevation myocardial infarction and (B) angina pectoris based on 100,000 simulations with a decision-analytic model. Ellipse, 95% CI; solid line, willingness to pay with a slope of ¥5 m per quality-adjusted life-year (QALY) gain.

Figure 3.

Cost-effective acceptability curve of percutaneous coronary intervention (PCI) over medical therapy: (A) ST-elevation myocardial infarction; (B) angina pectoris. Dotted line, willingness to pay at ¥5 m.

Discussion

In STEMI patients, PCI was cost-effective with an ICER <¥5 m compared with medical therapy. Even in several scenario analyses, ICER was <¥5 m, and the cost-effectiveness of PCI for STEMI patients was robust. In AP patients, ICER was <¥5 m in the main analysis, but >¥5 m in most of the scenario analyses. In the main analysis of AP patients based on the FAME 2 trial, FFR-guided PCI was cost-effective, assuming that FFR-guided PCI for symptomatic patients reduced cardiovascular events and improved QOL.

In STEMI patients, the therapeutic effect of PCI was greater than for medical therapy, indicating good cost-effectiveness for PCI. In a meta-analysis of PCI for STEMI, PCI was more effective than medical therapy.² We consider that the model used in the present study, which is based on meta-analysis and the J-MINUET study (Japan’s largest registry), is the optimal model.^2,15 We performed several scenario analyses to compensate for model assumptions. In the scenario analyses, even if the effect of PCI, the observation period, and patient age was changed, PCI remained cost-effective over medical therapy. Indeed, PCI for STEMI has been reported to be cost-effective.^6–9 Research from York in the UK reported that the ICER of PCI over medical treatment for AMI was £9,241, suggesting that the cost-effectiveness of PCI in MI patients is good in the UK.⁹ The present results are consistent with previous studies; therefore, the present finding that PCI for STEMI patients is cost-effective is valid.

In AP patients, the cost-effectiveness of FFR-guided PCI depended greatly on the premise of the analysis model. Although the cost-effectiveness of FFR-guided PCI for AP patients was good in the main analysis, estimated cost-effectiveness was poor when assuming that QOL improvement by FFR-guided PCI was limited. The clinical benefit of PCI for AP patients has not been established to the same degree as for STEMI patients.^2,34,35 When the results of clinical trials evaluating the effects of PCI vary, the cost-effectiveness of PCI also varies. Because FFR-guided PCI has recently become the main PCI procedure, we based our AP analysis model on the FAME 2 trial, which is an important clinical trial evaluating FFR-guided PCI.^3,4 We performed several scenario analyses to compensate for model assumptions, and FFR-guided PCI for asymptomatic patients was not found to be cost-effective. In asymptomatic patients, QOL did not improve after PCI, therefore the QALY difference between PCI and medical therapy was almost completely eliminated. As a result, the cost-effectiveness of PCI for asymptomatic patients was insufficient. Creating a model based on a trial in which an effect following PCI was not recognized, such as the COURAGE trial, would lead to underestimation of the cost-effectiveness of PCI.⁵ Also, according to the present scenario analyses, the cost-effectiveness of PCI changed significantly with the assumption that costs after PCI were higher or lower than costs before PCI. The results of cost-effectiveness analyses of PCI for AP patients vary in the literature.^10–14 Analyses based on the FAME 2 trial reported that FFR-guided PCI was cost-effective compared with medical therapy.¹⁴ In contrast, analyses based on the COURAGE trial reported that PCI was not cost-effective compared with medical therapy.¹⁰ In the present study, based on the FAME 2 trial, FFR-guided PCI for symptomatic AP patients was cost-effective compared with medical therapy. The cost-effectiveness of PCI for asymptomatic myocardial ischemia was poor.

The present study has the following clinical implications: primary PCI for STEMI should be performed more often in Japan, based on its cost-effectiveness. The cost-effectiveness of primary PCI in AP patients was good when performing FFR-guided PCI in symptomatic AP patients. Therefore, we should promote FFR-guided PCI for symptomatic AP patients, which is consistent with the current national insurance policy in Japan. Based on cost-effectiveness, medical treatment is preferred in asymptomatic patients with myocardial ischemia. Clinically, treatment should be determined based on both cost-effectiveness and on clinical course and social background of each patient.

Study Limitations

This study has several limitations. The first limitation is the model-based design. In model-based studies, when model assumptions vary, results vary. We carefully set reasonable models in the present study based on previous studies.^8,9,13,20,21 We selected the same parameters as those used in a meta-analysis and in large randomized control trials. We added scenario analyses and sensitivity analyses to reinforce the weak points of model research. The second limitation is that we did not compare PCI and coronary artery bypass grafting (CABG) in this study. In STEMI, PCI is the first choice for revascularization. In patients for whom PCI is difficult, CABG should be performed, but in this situation, there is little room to select a treatment based on cost-effectiveness. Additionally, in AP patients with 3-vessel disease or left main trunk disease, the alternative choice of PCI or CABG is important, clinically. In the present analysis, we compared PCI with medical therapy mainly in patients with single-vessel disease. When comparing PCI with CABG, it is necessary to consider other variables such as the severity of the coronary artery lesion; age; and sex; which could not be examined in the present study. Further studies are necessary to investigate the cost-effectiveness of PCI over CABG in Japan.

Conclusions

In STEMI patients, PCI was cost-effective compared with medical therapy. In AP patients, FFR-guided PCI for symptomatic patients could be cost-effective compared with medical therapy. FFR-guided PCI for asymptomatic patients with myocardial ischemia was not cost-effective.

Acknowledgments

We thank Jane Charbonneau, DVM, from Edanz Group (www.edanzediting.com/ac) for editing a draft of this manuscript. This work was supported by JSPS KAKENHI grant numbers JP 18K09989 and 19K10479.

Disclosures

The authors declare no conflicts of interest.

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