Low doses vs. high doses of the angiotensin converting‐enzyme inhibitor lisinopril in chronic heart failure: a cost‐effectiveness analysis based on the Assessment of Treatment with Lisinopril and Survival (ATLAS) study

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Abstract
Objective A cost‐effectiveness analysis of high and low doses of the angiotensin‐converting enzyme (ACE) inhibitor lisinopril in the treatment of chronic heart failure. Methods A cost‐effectiveness analysis using data from a randomized controlled trial, ATLAS, where 3164 patients with chronic heart failure were allocated to a high‐dose (daily target dose 32.5–35 mg) or low‐dose strategy (daily target dose 2.5–5.0 mg) of lisinopril. Differential costs were based on resource use data collected in the trial costed using UK unit costs. Cost‐effectiveness analysis related differential costs to differential life‐years during a 4‐year trial follow‐up. Results The mean total number of hospital in‐patient days per patient was 18.5 in the high dose group and 22.5 in the low dose group. Over the whole duration of the trial, the mean (S.D.) daily dose of lisinopril in the high‐dose group was 22.5 mg (15.7mg) compared to 3.2 mg (2.5 mg) in the low‐dose group. The mean difference in cost per patient was £397 lower in the high‐dose group [95% CI (high‐dose–low‐dose) −£1263 to £436]. Mean life‐years per patient were 0.085 years higher in the high‐dose group [95% CI (high‐dose–low‐dose) −0.0074 to 0.1706). Based on mean costs and life‐years, high‐dose therapy dominates low‐dose (less costly and more effective). Allowing for uncertainty in mean costs and life‐years, the probability of high‐dose therapy being less costly than low dose was 82%. If a decision maker is willing to pay at least £3600 per life‐year gained, the probability of high‐dose being more cost‐effective was 92%. Conclusions The ATLAS Study showed that the treatment of heart failure with high‐doses of lisinopril has a high probability of being more cost‐effective than low‐dose therapy.