Optimizing statin treatment for primary prevention of coronary artery disease.
BACKGROUND
Although treating to lipid targets ("treat to target") is widely recommended for coronary artery disease (CAD) prevention, some have advocated administering fixed doses of statins based on a person's estimated net benefit ("tailored treatment").


OBJECTIVE
To examine how a tailored treatment approach to statin therapy compares with a treat-to-target approach.


METHODS
Simulated model of population-level effects of treat-to-target and tailored treatment approaches to statin therapy.


METHODS
Statin trials from 1994 to 2009 and nationally representative CAD risk factor data.


METHODS
U.S. persons aged 30 to 75 years with no history of myocardial infarction.


METHODS
Lifetime effects of 5 years of treatment.


CONCLUSIONS
Societal and patient.


METHODS
Tailored treatment based on a person's 5-year CAD risk (simvastatin, 40 mg, for 5% to 15% CAD risk and atorvastatin, 40 mg, for CAD risk >15%) versus treat-to-target approaches that escalate statin dose per National Cholesterol Education Program [NCEP] III guidelines (including an intensive approach that advances treatment whenever intensification is optional by NCEP III criteria).


METHODS
Quality-adjusted life-years (QALYs).


RESULTS
Compared with the standard NCEP III approach, the intensive NCEP III approach treated 15 million more persons and saved 570,000 more QALYs over 5 years. The tailored strategy treated a similar number of persons, as did the intensive NCEP III approach, but saved 500,000 more QALYs and treated fewer persons with high-dose statins.


RESULTS
No circumstances were found in which a treat-to-target approach was preferable to tailored treatment.


CONCLUSIONS
Model assumptions were based on available clinical data, which included few persons 75 years or older.


CONCLUSIONS
A tailored treatment strategy prevents more CAD events while treating fewer persons with high-dose statins than low-density lipoprotein cholesterol-based target approaches. Results were robust, even with assumptions favoring a treat-to-target approach.


BACKGROUND
Department of Veteran Affairs Health Services Research & Development Service's Quality Enhancement Research Initiative.
Hayward
Rodney A
RA
University of Michigan and Veteran Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA. rhayward@umich.edu
Krumholz
Harlan M
HM
Zulman
Donna M
DM
Timbie
Justin W
JW
Vijan
Sandeep
S
D000328:Adult; D000368:Aged; D008078:Cholesterol, LDL / Q000097:blood; D002986:Clinical Trials as Topic; D003198:Computer Simulation; D003324:Coronary Artery Disease / Q000517:prevention & control*; D004334:Drug Administration Schedule; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000008:administration & dosage*; D008297:Male; D008875:Middle Aged; D011322:Primary Prevention; D019057:Quality-Adjusted Life Years; D012307:Risk Factors; D012680:Sensitivity and Specificity; D016896:Treatment Outcome
D008078:Cholesterol, LDL; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors