title: Cost-effectiveness of coronary artery calcium testing for coronary heart and cardiovascular disease risk prediction to guide statin allocation: the Multi-Ethnic Study of Atherosclerosis (MESA).
abstract: BACKGROUND
  The Multi-Ethnic Study of Atherosclerosis (MESA) showed that the addition of coronary artery calcium (CAC) to traditional risk factors improves risk classification, particularly in intermediate risk asymptomatic patients with LDL cholesterol levels <160 mg/dL. However, the cost-effectiveness of incorporating CAC into treatment decision rules has yet to be clearly delineated.
  
  
  OBJECTIVE
  To model the cost-effectiveness of CAC for cardiovascular risk stratification in asymptomatic, intermediate risk patients not taking a statin. Treatment based on CAC was compared to (1) treatment of all intermediate-risk patients, and (2) treatment on the basis of United States guidelines.
  
  
  METHODS
  We developed a Markov model of first coronary heart disease (CHD) and cardiovascular disease (CVD) events. We modeled statin treatment in intermediate risk patients with CAC≥1 and CAC≥100, with different intensities of statins based on the CAC score. We compared these CAC-based treatment strategies to a "treat all" strategy and to treatment according to the Adult Treatment Panel III (ATP III) guidelines. Clinical and economic outcomes were modeled over both five- and ten-year time horizons. Outcomes consisted of CHD and CVD events and Quality-Adjusted Life Years (QALYs). Sensitivity analyses considered the effect of higher event rates, different CAC and statin costs, indirect costs, and re-scanning patients with incidentalomas.
  
  
  RESULTS
  We project that it is both cost-saving and more effective to scan intermediate-risk patients for CAC and to treat those with CAC≥1, compared to treatment based on established risk-assessment guidelines. Treating patients with CAC≥100 is also preferred to existing guidelines when we account for statin side effects and the disutility of statin use.
  
  
  CONCLUSIONS
  Compared to the alternatives we assessed, CAC testing is both effective and cost saving as a risk-stratification tool, particularly if there are adverse effects of long-term statin use. CAC may enable providers to better tailor preventive therapy to patients' risks of CVD.
authors.affiliation: Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, Baltimore, Maryland, United States of America.
authors.forename: Eric T
authors.initials: ET
authors.lastname: Roberts
authors.affiliation: Johns Hopkins University School of Medicine, Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland, United States of America.
authors.forename: Aaron
authors.initials: A
authors.lastname: Horne
authors.affiliation: Johns Hopkins University School of Medicine, Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland, United States of America.
authors.forename: Seth S
authors.initials: SS
authors.lastname: Martin
authors.affiliation: Johns Hopkins University School of Medicine, Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland, United States of America.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Blaha
authors.affiliation: Brigham and Women's Hospital, Cardiovascular Division, Boston, Massachusetts, United States of America.
authors.forename: Ron
authors.initials: R
authors.lastname: Blankstein
authors.affiliation: UCLA School of Medicine, Department of Cardiology, Los Angeles, California, United States of America.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Budoff
authors.affiliation: Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, United States of America.
authors.forename: Christopher
authors.initials: C
authors.lastname: Sibley
authors.affiliation: Tufts University School of Medicine, Lemuel Shattuck Hospital, Boston, Massachusetts, United States of America.
authors.forename: Joseph F
authors.initials: JF
authors.lastname: Polak
authors.affiliation: Johns Hopkins Carey Business School and Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.
authors.forename: Kevin D
authors.initials: KD
authors.lastname: Frick
authors.affiliation: Johns Hopkins University School of Medicine, Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland, United States of America.
authors.forename: Roger S
authors.initials: RS
authors.lastname: Blumenthal
authors.affiliation: Johns Hopkins University School of Medicine, Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland, United States of America; Center for Healthcare Advancement and Outcomes, Baptist Health South Florida, Miami, FL, United States of America; Miami Cardiovascular Institute (MCVI), Baptist Health South Florida, Miami, FL, United States of America; Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, Miami, FL, United States of America.
authors.forename: Khurram
authors.initials: K
authors.lastname: Nasir
mesh_terms: D000328:Adult; D000368:Aged; D002118:Calcium / Q000378:metabolism*; D003327:Coronary Disease / Q000188:drug therapy / Q000191:economics / Q000208:ethnology / Q000378:metabolism; D003331:Coronary Vessels / Q000378:metabolism*; D005260:Female; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000008:administration & dosage / Q000009:adverse effects / Q000191:economics; D008297:Male; D008875:Middle Aged; D008954:Models, Biological; D017410:Practice Guidelines as Topic; D011446:Prospective Studies
chemical_list: D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D002118:Calcium