Statins may be cost-effective for lower-risk populations, model finds

Statin therapy may be a cost-effective way to prevent cardiovascular events in moderate- to low-risk populations without testing for high-sensitivity C-reactive protein (hs-CRP), a new study has found.

Researchers used a decision analytic Markov model to test three treatment strategies in hypothetical patients who had normal lipid levels and no coronary artery disease, peripheral arterial disease or diabetes mellitus. The treatment strategies tested were statin therapy according to existing Adult Treatment Panel (ATP) III guidelines (10-year predicted risk for coronary events >20%, or diabetes mellitus), statin therapy in patients with elevated hs-CRP levels but no other risk factors, and statin therapy in patients at predicted risk thresholds without hs-CRP testing. All three hypothetical cohorts were assumed to have lipid levels that matched the median levels in the JUPITER study: total cholesterol, 186 mg/dL; low-density lipoprotein cholesterol, 108 mg/dL; and high-density lipoprotein cholesterol, 49 mg/dL. Statin cost was assumed to be equal to that of simvastatin, 80 mg/d ($1.10 daily). The study results were published early online Sept. 27 by Circulation.

The authors found that treating with statins based on predicted risk thresholds but not hs-CRP testing was the most cost-effective strategy when statins were assumed to work equally well, regardless of hs-CRP level. Statin therapy based on hs-CRP testing was most cost-effective when normal hs-CRP levels were assumed to identify patients whose relative risk reduction on statins was less than 20%. ATP III guidelines were the optimal strategy if statin use was assumed to be associated with significant harms. An interactive presentation of the models' results is available online.

The authors concluded that prescribing statins according to predicted cardiovascular risk without hs-CRP testing in patients whose low-density lipoprotein levels are not elevated is the most effective of the three strategies, assuming that statins are safe and effective in this population. An accompanying editorial agreed with the authors that their results were "particularly sensitive" to variations in statins' presumed relative risk reduction and presumed long-term safety, and noted that determining the optimal strategy for primary prevention of cardiovascular events in the U.S. will be difficult.

"Further evaluations using well-informed decision analytic models such as that presented [here] will help inform health policy decision making relating to the primary prevention of cardiovascular disease in a manner that is consistent with the society goal of rational and judicious use of limited healthcare resources," the editorialist wrote.