Incremental benefit and cost-effectiveness of high-dose statin therapy in high-risk patients with coronary artery disease.
BACKGROUND
Recent clinical trials found that high-dose statin therapy, compared with conventional-dose statin therapy, reduces the risk of cardiovascular events in patients with acute coronary syndromes (ACS) and stable coronary artery disease (CAD). However, the actual benefit and cost-effectiveness of high-dose statin therapy are unknown.


RESULTS
We designed a Markov model to compare daily high-dose with conventional-dose statin therapy for hypothetical 60-year-old cohorts with ACS and stable CAD over patient lifetime. Pooled estimates for major clinical end points (all-cause mortality, myocardial infarction, stroke, rehospitalization, and revascularization) from relevant clinical trials were incorporated. Incremental benefit was quantified as quality-adjusted life-years (QALYs). Threshold analyses determined at what price difference high-dose statins would yield incremental cost-effective ratios below $50,000, $100,000, and $150,000 per QALY gained. In ACS patients, a high-dose versus conventional-dose statin strategy resulted in a gain of 0.35 QALYs. In threshold analyses, a high-dose statin strategy consistently yielded incremental cost-effective ratios below $30,000 per QALY even under conservative model assumptions. In stable CAD patients, a high-dose statin strategy yielded a gain of only 0.10 QALYs and was sensitive to model assumptions about statin efficacy. The daily cost difference between a high- and conventional-dose statin would need to be <$1.70, $2.65, and $3.55 to yield incremental cost-effective ratios below $50,000, $100,000, and $150,000 per QALY.


CONCLUSIONS
High-dose statin therapy is potentially highly effective and cost-effective in patients with ACS. In patients with stable CAD, however, the cost-effectiveness of high-dose statin therapy is highly sensitive to model assumptions about statin efficacy and cost. Use of high-dose statins can be supported on health economic grounds in patients with ACS, but the case is less clear for patients with stable CAD.
Chan
Paul S
PS
University of Michigan Department of Internal Medicine, Ann Arbor, MI, USA. paulchan@umich.edu
Nallamothu
Brahmajee K
BK
Gurm
Hitinder S
HS
Hayward
Rodney A
RA
Vijan
Sandeep
S
D000208:Acute Disease; D000789:Angina, Unstable / Q000191:economics / Q000517:prevention & control* / Q000628:therapy; D015331:Cohort Studies; D015897:Comorbidity; D003198:Computer Simulation; D003327:Coronary Disease / Q000191:economics / Q000453:epidemiology* / Q000628:therapy; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D004305:Dose-Response Relationship, Drug; D006760:Hospitalization; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000008:administration & dosage* / Q000191:economics / Q000627:therapeutic use; D006937:Hypercholesterolemia / Q000188:drug therapy* / Q000191:economics / Q000453:epidemiology; D008390:Markov Chains; D008875:Middle Aged; D008955:Models, Cardiovascular; D009203:Myocardial Infarction / Q000191:economics / Q000517:prevention & control* / Q000628:therapy; D009204:Myocardial Revascularization; D019057:Quality-Adjusted Life Years; D012306:Risk; D020521:Stroke / Q000191:economics / Q000517:prevention & control*; D013577:Syndrome
D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors