title: Strategies for Primary Prevention of Coronary Heart Disease Based on Risk Stratification by the ACC/AHA Lipid Guidelines, ATP III Guidelines, Coronary Calcium Scoring, and C-Reactive Protein, and a Global Treat-All Strategy: A Comparative--Effectiveness Modeling Study.
abstract: BACKGROUND
  Several approaches have been proposed for risk-stratification and primary prevention of coronary heart disease (CHD), but their comparative and cost-effectiveness is unknown.
  
  
  METHODS
  We constructed a state-transition microsimulation model to compare multiple approaches to the primary prevention of CHD in a simulated cohort of men aged 45-75 and women 55-75. Risk-stratification strategies included the 2013 American College of Cardiology/American Heart Association (ACC/AHA) guidelines on the treatment of blood cholesterol, the Adult Treatment Panel (ATP) III guidelines, and approaches based on coronary artery calcium (CAC) scoring and C-reactive protein (CRP). Additionally we assessed a treat-all strategy in which all individuals were prescribed either moderate-dose or high-dose statins and all males received low-dose aspirin. Outcome measures included CHD events, costs, medication-related side effects, radiation-attributable cancers, and quality-adjusted-life-years (QALYs) over a 30-year timeframe.
  
  
  RESULTS
  Treat-all with high-dose statins dominated all other strategies for both men and women, gaining 15.7 million QALYs, preventing 7.3 million myocardial infarctions, and saving over $238 billion, compared to the status quo, far outweighing its associated adverse events including bleeding, hepatitis, myopathy, and new-onset diabetes. ACC/AHA guidelines were more cost-effective than ATP III guidelines for both men and women despite placing 8.7 million more people on statins. For women at low CHD risk, treat-all with high-dose statins was more likely to cause a statin-related adverse event than to prevent a CHD event.
  
  
  CONCLUSIONS
  Despite leading to a greater proportion of the population placed on statin therapy, the ACC/AHA guidelines are more cost-effective than ATP III. Even so, at generic prices, treating all men and women with statins and all men with low-dose aspirin appears to be more cost-effective than all risk-stratification approaches for the primary prevention of CHD. Especially for low-CHD risk women, decisions on the appropriate primary prevention strategy should be based on shared decision making between patients and healthcare providers.
authors.affiliation: Brigham and Women's Hospital, Division of Cardiology, Boston, Massachusetts, United States of America.
authors.forename: Benjamin Z
authors.initials: BZ
authors.lastname: Galper
authors.affiliation: Columbia University Medical Center, Mailman School of Public Health, New York, New York, United States of America.
authors.forename: Y Claire
authors.initials: YC
authors.lastname: Wang
authors.affiliation: Columbia University Medical Center and New York-Presbyterian Hospital, Department of Medicine, New York, New York, United States of America; Columbia University Medical Center and New York-Presbyterian Hospital, Division of Cardiology, New York, New York, United States of America; Columbia University Medical Center and New York-Presbyterian Hospital, Department of Radiology, New York, New York, United States of America.
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Einstein
mesh_terms: D000328:Adult; D000368:Aged; D001241:Aspirin / Q000627:therapeutic use; D002097:C-Reactive Protein / Q000378:metabolism*; D002118:Calcium / Q000097:blood*; D002784:Cholesterol / Q000097:blood*; D003324:Coronary Artery Disease / Q000097:blood / Q000517:prevention & control; D003331:Coronary Vessels / Q000378:metabolism*; D005260:Female; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D008954:Models, Biological; D018570:Risk Assessment
chemical_list: D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D002097:C-Reactive Protein; D002784:Cholesterol; D001241:Aspirin; D002118:Calcium