OBJECTIVES: To update an estimate of the cost-utility of Implantable Cardioverter Defibrillator (ICD) versus Conventional Medical Treatment for primary prevention of cardiac arrhythmias from the National Health System (NHS) perspective.

METHODS: A 2011 cost-utility model was updated, differentiating patients with ischemic and non-ischemic cardiomyopathy, through: (1) systematic literature review including meta-analysis, (2) analysis of the usual clinical practice issues that could impact cost-utility -validated with cardiologists and arrhythmologists-, (3) unit costs from the Vall d'Hebron Hospital in Barcelona (2017), the Cantonera Project (Canary Islands) (2018) and NHS Nomenclator drug prices(2018),(4) mortality rates update (2018).

RESULTS: The review identified a new study (DANISH) performed in non-ischemic patients with a mean follow-up of 63 monthsA meta-analysis of the non ischemic patients incorporating the DANISH information showed clinical benefit of ICD on overall mortality with HR = 0.76 (0.63-0.90). The DANISH trial, independently, showed differences according to age groups, and, when differing by age (±65 years), only patients under 65 showed significant clinical benefit in mortality: HR = 0.82 (0.48-0.78). The meta-analysis performed also shown that ischemic patients had significant clinical benefit in mortality. Changes in the usual process of care and costs found were, among others, implantation through ambulatory surgery, generator replacement frequency and price of the devices, and all of them improved the cost-utility ratio of the ICD. The results found remained below a theoretical threshold of €20-25,000/QALY in patients with ischemic heart disease and in patients with non-ischemic heart disease under 65 years old. Alternatively, results were clearly above the threshold among patients with non-ischemic dilated cardiomyopathy.

CONCLUSIONS: ICD, considering a willingness to pay of €20-25,000/QALY, was not efficient for non-ischemic patients in general, but did for ischemic and non-ischemic under 65 years old. Decision-making according to efficiency criteria could be made pointing at older non-ischemic patients.