Model finds CYP2C19-guided DAPT cost-effective after PCI

A point-of-care CYP2C19 genetic test used to guide dual antiplatelet therapy prescribing was estimated to be cost-effective for patients with acute coronary syndrome undergoing percutaneous coronary intervention in a 40-year model of England’s National Health Service. The analysis compared CYP2C19-guided prescribing with current prescribing in two post-PCI populations: patients with ST-segment elevation myocardial infarction (STEMI) and patients with non-ST-segment elevation myocardial infarction or unstable angina (UA/NSTEMI). The findings are model-based estimates rather than outcomes directly observed in a clinical trial.

Researchers used a hybrid decision-tree and state-transition Markov model to calculate costs and quality-adjusted life-years (QALYs) for the two strategies. In the CYP2C19-guided approach, carriers of a loss-of-function allele were assigned prasugrel or ticagrelor, while non-carriers were assigned clopidogrel. This strategy was compared with current prescribing practice, in which guidelines recommend prasugrel or ticagrelor with aspirin as dual antiplatelet therapy after PCI for acute coronary syndrome, with clopidogrel reserved for people at high bleeding risk or with contraindications. Costs were expressed in pounds at 2024/25 prices and were considered from NHS and social services perspectives. Event rates and utility values came from published data, and sensitivity analyses were used to assess uncertainty in the model results.

For the STEMI population, the model estimated that CYP2C19-guided dual antiplatelet therapy would yield 0.0439 additional QALYs at an additional cost of £25. The resulting incremental cost-effectiveness ratio was £569 per QALY. In the UA/NSTEMI population, the modeled strategy yielded 0.0358 additional QALYs at an additional cost of £83, corresponding to an incremental cost-effectiveness ratio of £2,318 per QALY. At the analysis’s cost-effectiveness threshold of £20,000 per QALY, the strategy had an estimated probability of being cost-effective of 87.6% for STEMI and 94.3% for UA/NSTEMI. Based on these results, the study concluded that CYP2C19-guided prescribing was likely to be a cost-effective use of the NHS budget when compared with current prescribing practice for both modeled populations.

The analysis was limited to patients with acute coronary syndrome treated with PCI and was framed around NHS prescribing in England; it did not directly assess people who do not undergo PCI or care delivered in other health systems. Its conclusions also depend on the modeled treatment rules, event rates, utilities and cost inputs, which were drawn from published data rather than newly measured clinical or economic outcomes in this study. Although the model made the R implementation of the decision-analytic model publicly available for inspection and reuse, that availability does not eliminate the uncertainty inherent in the assumptions. The reported probabilities describe the model’s uncertainty, not proof that genotype-guided therapy improves survival, prevents myocardial infarction, reduces bleeding or otherwise improves clinical outcomes in a randomized trial. The study therefore addresses the modeled cost-effectiveness of a prescribing strategy, rather than directly demonstrating clinical benefit.

Subject of Research: Cost-effectiveness modeling of CYP2C19-guided dual antiplatelet therapy after PCI for acute coronary syndrome

Article Title: Implementing a CYP2C19-guided approach for prescribing dual antiplatelet therapy in acute coronary syndrome for patients undergoing percutaneous coronary intervention: a cost-effectiveness analysis

Article References: Mahboub-Ahari, A., Hilton, J., Rodrigues, M., McDermott, J., Body, R., Hayward, J., Newman, W. G., & Payne, K. (2026). Implementing a CYP2C19-guided approach for prescribing dual antiplatelet therapy in acute coronary syndrome for patients undergoing percutaneous coronary intervention: a cost-effectiveness analysis. BMC Pharmacology and Toxicology. https://doi.org/10.1186/s40360-026-01255-4

Image Credits: AI Generated

DOI: 10.1186/s40360-026-01255-4

Keywords: CYP2C19, acute coronary syndrome, dual antiplatelet therapy, percutaneous coronary intervention, pharmacogenomics, cost-effectiveness, Markov model, NHS, STEMI, UA/NSTEMI, Implementing, CYP2C19-guided