What Price to Pay?

What is a cynic? A man who knows the price of everything and the value of nothing. — —Oscar Wilde, Lady Windermere’s Fan Myocardial infarction and heart failure often combine at a deadly intersection defined by the natural history of the disease on one hand and the safety and benefit of available treatments on the other. Patients presenting acutely with these concomitant disorders are at high risk defined by the earliest and simplest clinical classification schema,1 static and dynamic risk models,2 and inclusion criteria for contemporary trials.3Article p 398 Millions of North Americans (and the larger global population) suffer these events. The residual sequelae of outpatient and emergency department visits, hospitalizations, procedures, and loss of function extract a heavy toll of diminished quality and quantity of life. As clinicians and scientists, our goal is to favorably alter this course when possible at all “costs” for our patients. Yet we cannot disregard all financial costs because even high-income countries do not have an endless supply of healthcare resources.4 This dilemma is especially dire in low-income countries where clinicians must necessarily choose between standard-of-care agents rather than assume their presence as background to promising new options (see the Figure). Hence, selecting those higher-risk patients likely to incur the greatest cost to the healthcare system while at the same time altering their cycle of rehospitalization is sure to be a winning ticket. Figure. The central role of value: intersecting between cost and benefit and between society and the individual. The cost of any therapy can be borne individually (eg, out-of-pocket medication payment) or by society (eg, ambulance dispatch for cardiac arrest). Likewise, the accrued benefit may be individual (aspirin after myocardial infarction) or societal (mass vaccination). Low- and high-cost therapies (standard of care and advanced therapies, respectively) alike …