Cost-effectiveness of heart failure pharmacotherapy withdrawal in recovered atrial fibrillation mediated cardiomyopathy: analysis of the WITHDRAW-AF randomized clinical trial.

BACKGROUND

The WITHDRAW-AF trial demonstrated HFrEF pharmacotherapy can be safely withdrawn in carefully selected patients with recovered atrial fibrillation-mediated cardiomyopathy post-ablation. In this study, we examined the economic implications of this strategy.

METHODS

We compared costs and outcomes of each strategy during the trial and through a 5-year Markov model. Functional status was assessed by VO2max and 6-min walk test distance (6MWT), and quality of life by the Minnesota Living with Heart Failure Questionnaire (MLHFQ) mapped to the EQ-5D-5L. Probabilistic sensitivity analysis was through 2000 Monte Carlo simulations.

RESULTS

In-trial medication cost savings were $1031/patient ($1572 vs $2604, p < 0.001). Over 5 years, projected modelled costs for withdrawal versus continuation were $3901 (95% CI: $3852-$3950) versus $8446 (95% CI: $8375-$8517). Outcomes favoured withdrawal; 6MWT in 61.8% of simulations (difference 29.39 m, 95% CI: 23.03-35.74), VO2max in 68.1% (difference 4.02 ml/kg/min, 95% CI: 3.49-4.44), and MLHFQ in 53.7% (difference 1.71, 95% CI: 0.57-2.84). QALYs were comparable (difference 0.003, 95% CI: -0.05-0.01).

CONCLUSION

In recovered atrial fibrillation-mediated cardiomyopathy, HFrEF pharmacotherapy withdrawal represented cost-minimisation without detriment to functional status or quality of life.