Cost implications of routine tirofiban use in the management of acute coronary syndromes

Background: Several studies have shown that glycoprotein IIb/IIIa receptor inhibitors confer benefit for patients admitted with acute coronary syndromes. However, these drugs are widely regarded as expensive. We therefore decided to assess the theoretical cost implications of introducing glycoprotein IIb/IIIa receptor inhibitors on our coronary care unit (CCU). Methods: We audited 304 admissions (188 male, mean age 68 years) with unstable angina or a non-q-wave myocardial infarction to the CCU of a large district general hospital between January and December 1998. The main outcome measure was eligibility for treatment with tirofiban in accordance with the entry and exclusion criteria of the PRISM-PLUS trial. Results: Of the 304 admissions, only 77 (25.3%) would have been eligible for randomisation in the PRISM-PLUS trial. The annual cost of selectively treating this subgroup with tirofiban would be £11,090 (Euro 18,520) per 100 admissions overall. Using tirofiban to treat all admissions with unstable angina and non-q-wave myocardial infarction would treat almost four times as many patients at a cost of £43,833 (Euro 73,201) per 100 admissions, with unproven benefits for the majority. Conclusions: We have found significant differences between patients treated in ‘real life’ and those enrolled into a randomised controlled trial, and demonstrated the importance of maintaining a patient registry in such trials. Deciding whether to treat only those patients for whom there is trial-based evidence of benefit, or all patients regardless of their similarity to trial populations, is an important factor which needs to be taken into account in preparing treatment protocols and in planning for drug expenditure.