Dados do Trabalho

Título

Custo-efetividade dos antagonistas dos receptores mineralocorticoides na insuficiência cardíaca com fração de ejeção reduzida: o caso brasileiro com redes bayesianas e diagramas de influência de Markov

Resumo

Background:Heart failure (HF) has a significant impact on health in middle-income countries, such as Brazil. MRAs are essential for the management of ICDS, but have been limited by side effects such as gynecomastia and hyperkalemia, such as spironolactone, which until recently was the only option available. However, the introduction of new MRAs, such as finerenone and eplerenone, may alter the dynamics of treatment, making it crucial to assess their cost-effectiveness to improve HF management.Methods: We used a Bayesian Network method supplemented by Markov Influence Diagrams to calculate incremental cost-effectiveness ratios (ICERs), expressed in international dollars (Int$) per quality-adjusted life year (QALY). The model included discontinuation rates for MRAs reflecting actual clinical practice, with a 5% yearly discount rate for costs and effectiveness. A systematic review followed by a network meta-analysis (NMA) was conducted to evaluate the relative effectiveness of MRAs, using data from a robust real-world cohort of 1,098 HFrEF patients. Costs were assessed from the perspective of Brazil's public health system, converted to Int$ for global comparison. Results: The NMA showed that spironolactone [HR:0.75 (95%CI 0.67-0.84)], eplerenone [HR:0.84 (95%CI 0.77-0.93)], and finerenone [HR:0.90 (95%CI 0.82-0.98)] significantly reduced the risk of all-cause mortality. Eplerenone [HR:0.60 (95%CI 0.41-0.90)] was the only MRA significantly decreasing HF-related hospitalizations, a key aspect in managing HFrEF. The analysis also indicated a higher risk of MRA discontinuation for finerenone (22%) and spironolactone (51%) compared to eplerenone. In cost-effectiveness assessments, finerenone was less favorable, while eplerenone showed an ICER of Int$2,614 (95%CI 1,851-3,470)/QALY compared to spironolactone. Both spironolactone and eplerenone were cost-effective versus no MRA therapy, with eplerenone especially advantageous below a willingness-to-pay threshold of Int$8,900 per QALY. Conclusion: Eplerenone is likely the most cost-effective MRA in Brazil, reducing HF-related hospitalizations and having a lower discontinuation rate compared to spironolactone. This emphasizes the importance of cost-effectiveness analysis in healthcare decisions, helping to develop targeted therapies for HFrEF.

Palavras Chave

insuficiência cardíaca; Custo-efetividade;

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