Cost-effectiveness evaluation of aspirin in primary prevention of myocardial infarction amongst males with average cardiovascular risk in Iran

Mohammadreza Amirsadri, Mohammad Javad Sedighi


Aspirin is one of the certified medicines commonly used for the secondary prevention of myocardial infarction (MI). Aspirin side effects and gastrointestinal bleeding, in particular, have arisen debates on its use for the primary prevention of MI. The present research evaluates the cost-effectiveness of the use of aspirin in the primary prevention of MI among Iranian men with average cardiovascular disease (CVD) risk, using Markov modeling technique. The incremental cost-effectiveness ratios (ICERs) estimated to be 864 USA dollars (USD) per quality-adjusted life years (QALY) gained and 782 USD per life years gained (LYG) for each patient in the base-case scenario (public tariffs and no discounting). This research proves cost-effectiveness of the use of aspirin in the primary prevention of MI in targeted population, since the assessed ICERs are quite under the recommended threshold by WHO which is one gross domestic product (GDP) per capita ($5315.1 for Iran in 2015).


Aspirin; Primary prevention; Cardiovascular diseases; Markov chain; Cost-effectiveness

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Murray CJL, Lopez AD. The global burden of disease: a comprehensive assessment of mortality & morbidity from diseases, injuries and risk factors in 1990 & projected to 2020. Cambridge, Mass: Harvard University Press; 1996. P. 1501.

Colin D. Mathers, Dejan Loncar. Updated projections of global mortality and burden of disease, 2002-2030. PLoS Med. 3(11): e442. doi:10.1371/journal.pmed.0030442.

Beyranvand MR LA, Alipour Parsa S, Motamedi MR, Kolahi AA. The quality of life after first acute myocardial infarction. Pajohandeh. 2011;15(6):264-272.

Salim Yusuf, Steven Hawken, Stephanie Ôunpuu, Tony Dans, Alvaro Avezum, Fernando Lanas, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet. 2004;364(9438):937-952.

Nichols M, Townsend N, Scarborough P, Rayner M. Cardiovascular disease in Europe 2014: epidemiological update. Eur Heart J. 2014;35: 2950-2959.

Rosamond W, Flegal K, Furie K, Go A, Greenlund K, Haase N, et al. Circulation. 2009;119(3):480-486.

Antiplatelet Trialists’ Collaboration. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ. 2002;324(7329):71–86.

Hennekens CH. Benefits and risks of aspirin in secondary and primary prevention of cardiovascular disease. In: UpToDate, Verheugt F, Cannon CP(Ed), UpToDate;2015. P. 4.

Pearson TA, Blair SN, Daniels SR, Eckel RH, Fair JM, Fortmann SP, et al. AHA guidelines for primary prevention of cardiovascular disease and stroke: 2002 update: consensus panel guide to comprehensive risk reduction for adult patients without coronary or other atherosclerotic vascular diseases. American Heart Association Science Advisory and Coordinating Committee. Circulation. 2002;106:388-391.

Jones Ca, Ross L, Surani N, Dharamshi N, Karmali K. Framingham ten-year general cardiovascular disease risk: agreement between bmi-based and cholesterol-based estimates in a South Asian convenience sample. PLoS ONE. 2015 March. 10(3): e119183. Doi:10.1371/journal.pone.0119183.

Nash DB, Nash SA. Reclassification of simvastatin to over-the-counter status in the United Kingdom: a primary prevention strategy. Am J Cardiol. 2004;94(9):35F–39F.

Bellingham C. Is pharmacy ready for OTC statins? Pharmaceutical Journal. 2004;271:8-9.

Smolina K, Wright FL, Rayner M, Goldacre MJ. Long-term survival and recurrence after acute myocardial infarction in England, 2004 to 2010. Circ Cardiovasc Qual Outcomes. 2012;5(4):532-540.

Drummond M, Sculpher M, Torrance G, O’Brien B, Stoddart G. Economic evaluation using decision analytic modelling. Methods for the economic evaluation of health care programmes. 3rd ed. New York: Oxford UniversityPress; 2005. pp. 280-282.

Sonnenberg FA, Beck JR. Markov models in medical decision making a practical guide. Med Decis Making. 1993;13(4):322–338.

McQuaid KR, Laine L. Systematic review and meta-analysis of adverse events of low-dose aspirin and clopidogrel in randomized controlled trials. Am J Med. 2006;119(8):624-638.

Edejer TT-T, Baltussen R, Adam T, Hutubessy R, Acharya A, Evans DB, Murray CJL. Making choice in health: WHO guide to cost-effectiveness analysis. Geneva: World Health Organization (WHO); 2003. P. 245.

Abdoli G. Estimation of social discount rate for Iran. Eco Res Rev. 2009;10:135–156.

Talaei M, Sarrafzadegan N, Sadeghi M, Oveisgharan Sh, Marshall T, Thomas N, et al. Incidence of cardiovascular diseases in an Iranian population: the Isfahan Cohort Study. Arch Iran Med. 2013;16(3):138-144.

Ward S, Jones ML, Pandor A, Holmes M, Ara R, Ryan A, Yeo W, Payne N. A systematic review and economic evaluation of statins for the prevention of coronary events. Health Technol Assess. 2007;11(14):1-160, iii-iv.

Eidelman RS, Hebert PR, Weisman SM, Hennekens CH. An update on aspirin in the primary prevention of cardiovascular disease. Arch Intern Med. 2003;163(17):2006-2010.

Tsutani K, Igarashi A, Fujikawa K, Evers T, Kubin M, Lamotte M, Annemans L. A health economic evaluation of aspirin in the primary prevention of cardiovascular disease in Japan. Intern Med. 2007;46(4):157-162.

Antithrombotic Trialists’ Collaboration. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ. 2002;324(7329):71-86.

Collaborative overview of randomised trials of antiplatelet therapy--I: Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. Antiplatelet Trialists' Collaboration. BMJ. 1994;308(6921):81-106.

García Rodríguez LA, Lin KJ, Hernández-Díaz S, Johansson S. Risk of upper gastrointestinal bleeding with low-dose acetylsalicylic acid alone and in combination with clopidogrel and other medications. Circulation. 2011;123:1108-1115.

Schleinitz MD, Weiss JP, Owens DK. Clopidogrel versus aspirin for secondary prophylaxis of vascular events: a cost-effectiveness analysis. Am J Med. 2004;116(12):797-806.

Serrano P, Lanas A, Arroyo MT, Ferreira IJ. Risk of upper gastrointestinal bleeding in patients taking low-dose aspirin for the prevention of cardiovascular diseases. Aliment Pharmacol Ther. 2002;16:1945–1953.

Mohammadin Hafshejani AB, Sarrafzadegan N, Attar Moghaddam HR, Hosseini S, Asadi Lari M. Predictive factors of survival in patients with an acute myocardial infarction among genders in Iran. J Isfahan Med Sch. 2012;30(209):1611-1621.

Farkhani EM, Baneshi MR, Zolala F. Survival rate and its related factors in patients with acute myocardial infarction. Med J Mashhad Univ Med Sci. 2014;57(4):636-646.

Ghafarian SH, Javan AR, Hatamipoor E, Mousavizadeh A, Ghaedi H, Jabarinejad A, Mohammadi Baghmallaei M. Survival rate and its related factors in patients with acute myocardial infarction. Armaghan Danesh. 2006;11(1):93-104.

Amani F, Hajizadeh E, Hoseinian F. Survival rate in MI patients. Koomesh. 2008;9(2):131-138.

Soltanian AR, Mahjub H, Goudarzi S, Nabi-Pour I, Jamali M. Five years survival rate in patients with myocardial infarction in Bushehr. Sci Hamadan Univ Med Sci. 2009;16(3):33-37.

Statistical Center of Iran, Selected findings of the 2011 national population and housing census. (2012). Accessed 08 April 2016.

Mousavi Sh, Tousi J, Fatemi R, Babaiee M, Rabizadeh MA. Evaluation of change in etiology and epidemiology of upper gastrointestinal bleeding in a community based study. Govaresh (in Persian). 2006;11(2):80-85.

Kaviani MJ, Pirastehfar M, Azari A, Saberifiroozi M. Etiology and outcome of patients with upper gastrointestinal bleeding: A study from south of Iran. Saudi J Gastroenterol. 2010;16(4):253–259.

Smith SM. Campbell JD. Cost-effectiveness of renin-guided treatment of hypertension. Am J Hypertens. 2013;26(11):1303-1310.

Lamotte M, Annemans L, Evers T, Kubin M. A multi-country economic evaluation of low-dose aspirin in the primary prevention of cardiovascular disease. Pharmacoeconomics. 2006;24(2):155-169.

The Central Bank of Iran (CBI); Exchange Rates. (2015). Accessed 11 April 2016.

Amirsadri MR, Hassani A. Cost-effectiveness and cost-utility analysis of OTC use of simvastatin 10 mg for the primary prevention of myocardial infarction in Iranian men. Daru. 2015;23:56. DOI:10.1186/s40199-015-0129-2.

Ministry of Health and Medical Education; Tarrif book of health services. index.aspx?fkeyid=&siteid=431&pageid=54142 (2014). Accessed 15 March 2016.

O'Brien BJ, Briggs AH. Analysis of uncertainty in health care cost-effectiveness studies: an introduction to statistical issues and methods. Stat Methods Med Res. 2002;11(6):455-468.

Briggs AH, Gray AM. Handling uncertainty when performing economic evaluation of healthcare interventions. Health Technol Assess. 1999;3(2): 1-134.

World Bank Group, GDP per capita, countries/IR?display=default, accessed in March 2016.

Greving JP, Buskens E, Koffijberg H, Algra A. Cost-effectiveness of aspirin treatment in the primary prevention of cardiovascular disease events in subgroups based on age, gender, and varying cardiovascular risk. Circulation. 2008;117(22): 2875-2883.

Pignone M, Earnshaw S, Tice J.A, Pletcher M.J, Aspirin, statins, or both drugs for the primary prevention of coronary heart disease events in men: A cost–utility analysis. Ann Intern Med. 2006;7;144(5):326-336.


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