Cost-Effectiveness of Mineralocorticoid Receptor Antagonists in Ischemic and Nonischemic Heart Failure With Reduced Ejection Fraction: Perspective From a Universal Healthcare System

Author(s)

Koeche, Cristiane ; Nogueira, Ana Claudia Cavalcante ; Amaral, Giselle Pinto da Silva ; Guimaraes, Adriana J. B. A. ; Neiva, Yasmim Botelho ; de Souza, Alexandre Magno Oliveira ; Fernandez, Marta Duran ; Rohde, Luis Eduardo ; Sposito, Andrei C. ; de Carvalho, Luiz Sergio F.

• Document type: Journal article
• Source: VALUE IN HEALTH REGIONAL ISSUES; v. 47, p. 9-pg., 2025-05-01.

Abstract

Objectives: Mineralocorticoid receptor antagonists (MRAs) are cornerstones in the management of heart failure (HF) with reduced ejection fraction (HFrEF). New MRAs with improved safety profile, such as finerenone and eplerenone, were recently introduced. However, because of typical budget restrictions in middle-income countries, evaluating their cost-effectiveness is essential for optimizing treatment strategies. Methods: We used a Bayesian network and Markov influence diagrams to estimate the incremental cost-effectiveness ratios (ICERs) in international dollars (Int$) per quality-adjusted life-year (QALY). Our model was fed by a systematic review and a network meta-analysis to compare MRAs effectiveness and used data from a cohort of 1066 Brazilian individuals with HFrEF (36% with ischemic and 64% with nonischemic disease). Results: Over a 10-year time horizon, the treatment with spironolactone, eplerenone, and finerenone compared with no MRA utilization yielded discounted QALY per person of 0.072, 0.111, and 0.034, respectively. The ICERs were Int$7955, Int$6460, and Int$109 840 per QALY gained, respectively. Compared with spironolactone, eplerenone showed an ICER of Int$6178 per QALY gained. Assuming a willingness-to-pay threshold of 1 Brazilian per capita gross domestic product (Int$17 589) per QALY gained, the probabilistic sensitivity analyses suggest that spironolactone and eplerenone were cost-effective, respectively, in 87% and 92% of iterations. The 95% CIs were Int$2282 to Int$13 149 for spironolactone and Int$1795 to Int$12 351 for eplerenone per QALY gained. These findings were consistent across several scenarios including ischemic/ nonischemic HF. Conclusions: Eplerenone is likely the most cost-effective MRA in Brazil considering individuals with both ischemic and nonischemic HFrEF. (AU)

• FAPESP's process: 22/14190-5 - Brazilian Initiative for Population Health Management (Clarity:iGESTO): impact of active monitoring and health education on hospitalizations and control of cardiovascular risk factors
• Grantee: Marta Duran Fernandez
• Support Opportunities: Research Grants - Innovative Research in Small Business - PIPE