Evaluating the Impact and Cost-Effectiveness of Statin Use Guidelines for Primary Prevention of Coronary Heart Disease and Stroke

Abstract

Background Statins are effective in primary prevention of atherosclerotic cardiovascular disease. The 2013 American College of Cardiology/American Heart Association (ACC-AHA) guideline expands recommended statin use, but its cost-effectiveness has not been compared with other guidelines. Methods We used the Cardiovascular Disease (CVD) Policy Model to estimate the cost-effectiveness of the ACC-AHA, relative to current use, Adult Treatment Panel III (ATP III) guidelines, and universal statin use in all men age 45-74 years and women age 55-74 years over a 10-year horizon from 2016 to 2025. Sensitivity analyses varied costs, risks, and benefits. Main outcomes were incremental cost-effectiveness ratios (ICER) and numbers needed to treat for ten years per quality-adjusted life-year gained (NNT/QALY). Results Each approach produces substantial benefits and net cost savings relative to the status quo. Full adherence to the ATP III guideline would result in 8.8 million more statin users than the status quo, at an NNT/QALY of 35. The ACC-AHA guideline would potentially result in up to 12.3 million more statin users than the ATP III guideline, with a marginal NNT/QALY of 68. Moderate-intensity statin use in all men 45-74 and women 55-74 would result in 28.9 million more statin users than the ACC-AHA guideline, with a marginal NNT/QALY of 108. In all cases, benefits would be greater in men than women. Results vary moderately with different risk thresholds for instituting statins and statin toxicity estimates, but greatly depend on the disutility caused by daily medication use (pill burden). Conclusions At a population level, the ACC-AHA guideline for expanded statin use for primary prevention is projected to treat more people, save more lives, and cost less compared with ATP III, in both men and women. Whether individuals benefit from long-term statin use for primary prevention depends more on the disutility associated with pill burden than their degree of cardiovascular risk.

When to Start a Statin Is a Preference-Sensitive Decision

“…1 These findings are consistent with previous reports, 2,3 but their results further suggest that starting a statin at age 40 in everyone regardless of CVD risk would extend statin treatment to over 28 million more Americans but would further and substantially improve the public’s health, but only if the disutility associated with pill burden is quite low.…”

Statins for atherosclerotic cardiovascular disease prevention in people living with HIV in Thailand: a cost‐effectiveness analysis

“…At the start of each annual cycle, the model estimated an individual's probability of transitioning from the healthy state to one of the CVD states based on their D:A:D CVD risk score [24,55]. The D:A:D equation is the only well-validated Acute MI c 0.0076 (0.0051 to 0.0106) [52] Acute ischemic stroke c 0.0242 (0.0158 to 0.0335) [52] Acute hemorrhagic stroke c 0.0242 (0.0158 to 0.0335) [52] Diabetes, average toll/individual taking statin/year c 0.00005 (0.00003 to 0.00007) [47,52] Myopathy, average toll/individual taking statin/year c 0.0000010 (0.0000007 to 0.0000012) [49,52] Daily statin administration/pill burden c 0.00000 (0.00000 to 0.00384) [53] Discounting and time horizon…”

The glucocorticoid‐induced leucine zipper mediates statin‐induced muscle damage

“…Since their introduction in 1987, statin prescription rates have risen, as shown by several studies in different populations, positioning them among the most prescribed drug classes worldwide. Given the high prevalence of CVD and the favorable data on CVD prevention by statins, this tendency seems to be maintained.…”