ABSTRACT
BACKGROUND: Patients with Wolff-Parkinson-White syndrome fall into four risk groups: those with (1) prior cardiac arrest, (2) paroxysmal supraventricular tachycardia or atrial fibrillation (PSVT/AF) with hemodynamic compromise, (3) PSVT/AF without hemodynamic compromise, and (4) no symptoms. METHODS AND RESULTS: For each group, we developed a cost-effectiveness analysis examining five clinical management strategies: (1) observation, (2) observation until a cardiac arrest dictates the need for therapy, (3) initial drug therapy guided by noninvasive monitoring, (4) initial radiofrequency ablation (RFA), and (5) initial surgical ablation. We used a Markov simulation model to estimate life expectancy and costs for patients whose ages are between 20 and 60 years. The model includes the risks of cardiac arrest, PSVT/AF, drug side effects, procedure-related complications and mortality, the efficacy of drugs and RFA, and costs. Based on literature and expert opinion, we assumed that the annual risks of cardiac arrest are 0.01%, 0.05%, and 0.5%, respectively, in patients who are asymptomatic, who had PSVT/AF without hemodynamic compromise, or who had PSVT/AF with hemodynamic compromise. We also assumed that RFA has an overall efficacy of 92% in preventing cardiac arrest and arrhythmias. Our model predicts that RFA should yield a life expectancy greater than or equal to other strategies. In cardiac arrest survivors and patients who have had PSVT/AF with hemodynamic compromise, our model suggests that RFA should both prolong survival and save resources. For patients with PSVT/AF without hemodynamic compromise, the marginal cost-effectiveness of attempted RFA (followed by conservative treatment if the RFA fails) ranges from $6600 per quality-adjusted life year (QALY) gained for 20-year-old patients to $19,000 per QALY gained for 60-year-old patients. For asymptomatic patients, RFA costs from $174,000 per QALY gained for 20-year-old patients to $540,000 per QALY gained for 60-year-old patients. CONCLUSIONS: Our analysis supports the emerging practice of performing RFA in patients with Wolff-Parkinson-White syndrome who survive cardiac arrest or who experience PSVT/AF but also supports the current practice of observing asymptomatic patients.
