Data support giving primary prevention statin therapy to several million more people
A cost-effectiveness analysis provides economic justification for the 2018 American guideline recommendation to consider statin treatment in certain patients with borderline risk, investigators showed.
Adding preventive statins to such patients -- who have predicted 10-year absolute risk of atherosclerotic cardiovascular disease in the 5.0%-7.4% range and elevated LDL cholesterol -- would make sense at currently accepted willingness-to-pay thresholds, according to Andrew Moran, MD, MPH, of Columbia University Medical Center/NewYork-Presbyterian Hospital in New York City, and colleagues:
- Cost-saving where LDL is 160-189 mg/dL: increase in lifetime quality-adjusted life-years (QALYs), and with lower costs to boot
- Cost-saving where LDL is 130-159 mg/dL: increase in QALYs and with lower costs
- Highly cost-effective in the remainder of people whose absolute risk is at least 5.0% ($33,558 per lifetime QALY gained)
It appears that "treating all patients at borderline risk regardless of LDL-C level would likely be highly cost-effective," Moran's group concluded in JAMA Cardiology.
High LDL cholesterol (≥160 mg/dL) is one risk-enhancing factor that the latest American College of Cardiology and American Heart Association guidelines had said would make a borderline-risk patient eligible for statins.
"We projected that expanding statin treatment from current standard care (about 35 million statin-eligible U.S. adults in 2019) to include individuals with borderline risk and LDL-C levels of 160 to 189 mg/dL would add about 2 million U.S. adults, to include those with borderline risk and LDL-C levels of 130 to 159 mg/dL would add another 4 million, and to include the remainder of individuals with borderline risk would add another 5 million," the authors wrote.
However, it is still not cost-effective to treat people with LDL cholesterol under 100 mg/dL with statins -- this group may even be harmed, they cautioned.
Their cost-effectiveness study was based on 100 computer-simulated cohorts created by probabilistic sampling of the 1999-2014 U.S. National Health and Nutrition Examination Surveys. Model variables were derived from analysis of the published literature, including six pooled U.S. cohort studies.
Lifetime QALY gains and financial costs in 2019 U.S. dollars were projected and discounted 3.0% annually by the investigators.
Cohorts were simulated at ages 40, 50, and 60. They were equally split between men and women, and accounted for younger patients not adhering to statin treatment and the potential for non-cardiovascular events in long-term users.
Mean absolute risk climbed from 1.8% at age 40 to 7.4% at 60; average LDL cholesterol levels went from 125.8 mg/dL at age 40 to 126.9 mg/dL at age 50 before falling to 122.3 mg/dL at 60.
On subgroup analysis, patients with higher baseline LDL cholesterol gained more QALYs, and cost-effectiveness increased with LDL level and 10-year absolute risk.
Moran and colleagues acknowledged that they assumed a direct association between baseline LDL cholesterol levels and statin benefit without accounting for mediators of statin efficacy such as non-HDL cholesterol or apolipoprotein B.
Finally, combining data from heterogeneous sources could also have led to non-generalizable results, according to the authors.
Moran disclosed support from the National Heart, Lung, and Bloo
Source Reference: Kohli-Lynch CN, et al "Cost-effectiveness of low-density lipoprotein cholesterol level-guided statin treatment in patients with borderline cardiovascular risk" JAMA Cardiol 2019; DOI: 10.1001/jamacardio.2019.2851.
Read the original article on Medpage Today: Statins Make Economic Sense for Borderline-Risk Patients