Abstract
BackgroundSeveral approaches have been proposed for risk-stratification and primary prevention of coronary heart disease (CHD), but their comparative and cost-effectiveness is unknown.MethodsWe constructed a state-transition microsimulation model to compare multiple approaches to the primary prevention of CHD in a simulated cohort of men aged 45–75 and women 55–75. Risk-stratification strategies included the 2013 American College of Cardiology/American Heart Association (ACC/AHA) guidelines on the treatment of blood cholesterol, the Adult Treatment Panel (ATP) III guidelines, and approaches based on coronary artery calcium (CAC) scoring and C-reactive protein (CRP). Additionally we assessed a treat-all strategy in which all individuals were prescribed either moderate-dose or high-dose statins and all males received low-dose aspirin. Outcome measures included CHD events, costs, medication-related side effects, radiation-attributable cancers, and quality-adjusted-life-years (QALYs) over a 30-year timeframe.ResultsTreat-all with high-dose statins dominated all other strategies for both men and women, gaining 15.7 million QALYs, preventing 7.3 million myocardial infarctions, and saving over $238 billion, compared to the status quo, far outweighing its associated adverse events including bleeding, hepatitis, myopathy, and new-onset diabetes. ACC/AHA guidelines were more cost-effective than ATP III guidelines for both men and women despite placing 8.7 million more people on statins. For women at low CHD risk, treat-all with high-dose statins was more likely to cause a statin-related adverse event than to prevent a CHD event.ConclusionsDespite leading to a greater proportion of the population placed on statin therapy, the ACC/AHA guidelines are more cost-effective than ATP III. Even so, at generic prices, treating all men and women with statins and all men with low-dose aspirin appears to be more cost-effective than all risk-stratification approaches for the primary prevention of CHD. Especially for low-CHD risk women, decisions on the appropriate primary prevention strategy should be based on shared decision making between patients and healthcare providers.
Highlights
Cardiovascular disease, and in particular coronary heart disease (CHD), is the leading cause of death and disability-associated life years both globally and in the United States [1,2]
Treat-all with high-dose statins dominated all other strategies for both men and women, gaining 15.7 million quality adjusted life years (QALY), preventing 7.3 million myocardial infarctions, and saving over $238 billion, compared to the status quo, far outweighing its associated adverse events including bleeding, hepatitis, myopathy, and new-onset diabetes
At generic prices, treating all men and women with statins and all men with low-dose aspirin appears to be more costeffective than all risk-stratification approaches for the primary prevention of CHD
Summary
Cardiovascular disease, and in particular coronary heart disease (CHD), is the leading cause of death and disability-associated life years both globally and in the United States [1,2]. Recently-released ACC/AHA guidelines on the treatment of cholesterol move away from treating a person based on reaching a goal LDL-C and utilize the Pooled Cohort Risk Equation (PCE) instead of FRS to determine a person’s global ASCVD risk These guidelines initiate statin treatment if a person is diabetic or has an LDL-C > 190 mg/dl, but, unlike ATP III, treatment for non-diabetics with an LDL-C < 190 is initiated based solely on the risk of future cardiovascular disease and does not utilize a threshold LDL-C level to determine the need to initiate treatment or a target LDL-C to achieve once treatment has been started [7–8]. Several approaches have been proposed for risk-stratification and primary prevention of coronary heart disease (CHD), but their comparative and cost-effectiveness is unknown
Sign-in/Register to view highlights & summary Sign-in/Register to access full text options 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a callDisclaimer: All third-party content on this website/platform is and will remain the property of their respective owners and is provided on "as is" basis without any warranties, express or implied. Use of third-party content does not indicate any affiliation, sponsorship with or endorsement by them. Any references to third-party content is to identify the corresponding services and shall be considered fair use under The CopyrightLaw.
