Original Title: Time to Cost-Effectiveness Following Stroke Reduction Strategies in AF Warfarin vs. NOACs vs. LAA Closure. Reference: Vivek Y. Reddy et al. J Am Coll Cardiol. 2015;66(24):2728-2739.

Left atrial appendage closure and the new anticoagulants (NOACs) have emerged as safe and effective alternatives to warfarin for stroke in patients with non-valvular atrial fibrillation.

This analysis assessed the cost/effectiveness of warfarin, NOACs and left atrial appendage closure with the Watchman device (Boston Scientific, Marlborough) at multiple points over a time horizon.

The Markov model was used to project the life time cost (20 years) in 70 year old patients with a moderate risk of stroke and bleeding.

The clinical events rate, post stroke evolution and quality of life were obtained mainly from the PROTECT AF study (Watchman Left Atrial Appendage System for Embolic Protection in Patients with Atrial Fibrillation) and the meta-analysis comparing warfarin to NOACs.

As regards warfarin, the left atrial appendage closure was cost effective at 7 years and the NOACs, at 16 years.

At sensitivity analysis, the left appendage closure device was cost effective compared to warfarin, even though procedure costs were doubled.

Conclusion
Both the NOACs and the left atrial appendage closure device Watchmanwere cost effective compared to warfarin. These outcomes should be considered in drafting the guidelines for stroke prevention in atrial fibrillation patients.

Editorial Comment
All calculations in this study were made in US dollars in 2015,in the US. In other countries, costs vary and this could modify the cost effectiveness ratio.