Abstract

Background and Aims Apixaban was superior to aspirin for the prevention of stroke or systemic embolism in participants with subclinical atrial fibrillation (SCAF) in the Apixaban for the Reduction of Thrombo-Embolism in Patients with Subclinical Atrial Fibrillation (ARTESiA) trial. This was especially true for those with CHA2DS2-VASc score >4. Understanding the cost-effectiveness of treating SCAF is important for decision makers. Methods Canadian, UK, German and US direct healthcare costs (in 2023 USD) were applied to hospitalized events (including strokes and bleeds) and study drugs for all participants with a CHA2DS2-VASc score >4 to determine the mean cost per participant during the trial (mean follow-up 3.5 years). A daily cost of $0.63, $0.11, $2.26, and $6.06 for apixaban in Canada, UK, Germany and the US was used. If in-trial results were not cost-saving (below $0), the prospective plan was to perform a lifetime cost-effectiveness analysis using a Markov model and a willingness-to-pay of 50,000 USD per Quality Adjust Life-Year (QALY). Results After considering the cost of study medication and clinical events over 3.5 years, apixaban was dominant (cost-saving and more effective) in Canada (-$2,301) and the UK (-$902) but cost more in Germany and the US ($600 and $1,990 respectively). Over a lifetime, treatment with apixaban produced a net gain of 0.107 QALYs, but with costs in both Germany ($2,623 more) and the US ($9,110 more); yielding an incremental cost effectiveness ratio of $24,514 per QALY for Germany and $85,140 for the US. Conclusion In patients with SCAF and a CHA2DS2-VASc score >4, apixaban is cost-saving in Canada and the UK and cost-effective in Germany. Apixaban was not cost-effective in the US under the base cost assumption but would be cost-effective at a daily cost of $4.35, and cost saving at $3.59.