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Cost-Effectiveness of 3-Hydroxy-3-Methylglutaryl Coenzyme A Reductase Inhibitor Therapy in Older Patients with Myocardial Infarction

David A. Ganz, BA; Karen M. Kuntz, ScD; Gretchen A. Jacobson, BA; and Jerry Avorn, MD
[+] Article and Author Information

From Harvard Medical School, Brigham and Women's Hospital, and Harvard School of Public Health, Boston, Massachusetts.


Acknowledgments: The authors thank Sue J. Goldie, MD, MPH, for helpful comments on an earlier draft of this manuscript and Sharon Hawley for assistance in the background research necessary for the preparation of this paper.

Grant Support: By a core grant to the Division of Pharmacoepidemiology and Pharmacoeconomics by Brigham and Women's Hospital, and by a research stipend from Harvard Medical School (Mr. Ganz).

Requests for Single Reprints: Jerry Avorn, MD, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, 221 Longwood Avenue, Suite 341, Boston, MA 02115.

Requests To Purchase Bulk Reprints (minimum, 100 copies): the Reprints Coordinator; phone, 215-351-2657; e-mail, reprints@mail.acponline.org.

Current Author Addresses: Mr. Ganz and Dr. Avorn: Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, 221 Longwood Avenue, Suite 341, Boston, MA 02115.

Dr. Kuntz: Center for Risk Analysis, Harvard School of Public Health, 718 Huntington Avenue, Boston, MA 02115.

Ms. Jacobson: Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115.

Author Contributions: Conception and design: D.A. Ganz, G.A. Jacobson, J. Avorn.

Analysis and interpretation of the data: D.A. Ganz, G.A. Jacobson, J. Avorn.

Drafting of the article: D.A. Ganz, G.A. Jacobson, J. Avorn.

Critical revision of the article for important intellectual content: D.A. Ganz, K.M. Kuntz, J. Avorn.

Final approval of the article: D.A. Ganz, K.M. Kuntz, G.A. Jacobson, J. Avorn.

Statistical expertise: K.M. Kuntz.

Collection and assembly of data: D.A. Ganz.


Ann Intern Med. 2000;132(10):780-787. doi:10.7326/0003-4819-132-10-200005160-00003
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Recent large-scale randomized, controlled trials of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) have shown statistically significant reductions in cardiovascular events, strokes, and total mortality among selected groups, including patients with risk factors for vascular disease or a history of vascular disease (15). In addition, cost-effectiveness analyses of the Scandinavian Simvastatin Survival Study and the West of Scotland Coronary Prevention Study have shown favorable cost-effectiveness ratios (67). A limitation of the randomized, controlled trials of statin therapy published to date, however, has been their failure to enroll patients older than 75 years of age. Ongoing randomized, controlled trials are including patients in this age category, but results will not be available for some time (89). Meanwhile, analyses of data from two secondary prevention trials, the Scandinavian Simvastatin Survival Study and the Cholesterol and Recurrent Events (CARE) trial, have found that participants 65 to 70 years of age and those 65 to 75 years of age, respectively, experienced statistically significant reductions in cardiac end points similar to those seen in trial participants as a whole (1011). These results raise the prospect of extending the use of statins to patients older than 75 years of age with established coronary heart disease (12). Although the issue of efficacy in patients older than 75 years of age will not be resolved definitively until trials of patients in this age group are published, decision-analytic models can test various assumptions about efficacy to gauge the potential cost-effectiveness of statins in this context. We modeled the cost-effectiveness of statin therapy in a hypothetical cohort of patients 75 to 84 years of age with a history of myocardial infarction by extrapolating results from published randomized, controlled trials and epidemiologic data.

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Figures

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Figure 1.
Markov model.MI

Health states are in ovals. Arrows represent allowed transitions. “Baseline” represents the starting state for all patients; they can remain in that state, go on to have a stroke or a recurrent myocardial infarction ( ), or die.

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Figure 2.
Percentage reduction by statins of fatal myocardial infarction (MI), nonfatal MI, and stroke combined compared with cost-effectiveness ratios.

Each curve represents a different hypothetical annual cost for drug therapy, ranging from $250 per year to $2000 per year. QALY = quality-adjusted life-year.

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Summary for Patients

Cost-Effectiveness of Lowering Cholesterol in Older Patients after Heart Attack

The summary below is from the full report titled “ Cost-Effectiveness of 3-Hydroxy-3-Methylglutaryl Coenzyme A Reductase Inhibitor Therapy in Older Patients with Myocardial Infarction.” It is in the 16 May 2000 issue of Annals of Internal Medicine (volume 132, pages 780-787). The authors are D.A. Ganz, K.M. Kuntz, G.A. Jacobson, and J. Avorn.

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