Aspirin, Statins, or Both Drugs for the Primary Prevention of Coronary Heart Disease Events in Men: A Cost–Utility Analysis

Pignone, et. al. (1) concluded that adding a statin to aspirin therapy is cost effective then the CHD risk is greater than 10% (1). In their model, the authors used a yearly statin cost of $730., which was the average Red Book cost between 10mg of lovastatin and simvastatin.

I find in my clinical practice, that patients need higher doses of these drugs or more potent statins or even a second lipid lowering drug to reach the guidelines set by the NCEP panel (2). These approaches are more expensive than the model indicates. Does he author's model tell us at what 10 year CHD risk a patient would need to be to make it cost effective to use 80mg of atorvastatin, for instance?

Previous authors have questioned the cost effectiveness of statins in primary prevention for younger, lower risk patients (3). I hope that the conclusions in the article by Pignone, et al.(1) is heeded by the organizations that are trying to measure quality. Bbaseline CHD risk of patients should be considered when report cards are issued. However, in this era of looming "pay for performance" incentives, physicians may feel compelled to statin therapy in more patients and try to get all patients to certain LDL goals, regardless of their estimated 10 year risk.

references: 1. Michael Pignone, Stephanie Earnshaw, Jeffrey A. Tice, and Mark J. Pletcher Aspirin, Statins, or Both Drugs for the Primary Prevention of Coronary Heart Disease Events in Men: A Cost"“Utility Analysis Ann Intern Med 2006; 144: 326-336

2. National Cholesterol Educational Program. Executive Summary of the Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel 111) JAMA. 2001;285:2486-97

3. Prosser LA, Stinnett AA, Goldman PA, Williams LW, Hunink MG, Goldman L, Weinstein MC. Related Articles, Links

Cost-effectiveness of cholesterol-lowering therapies according to selected patient characteristics. Ann Intern Med. 2000 May 16;132(10):769-79.

Conflict of Interest:

None declared

To the Editor,

The effectiveness of high-dose statins or combination lipid lowering therapy for primary prevention of coronary heart disease events has not been studied to date and was not included as part of our model. The trials that formed the basis of our estimates of costs and effectiveness in CHD risk reduction employed low to medium doses of a single agent and used minimal or no adjustment based on lipid levels. (1) If more aggressive lipid lowering treatment were to be found more effective in CHD event prevention, then further analyses would need to consider whether the additional costs and potential increase in adverse effects were sufficiently off-set by the additional degree of effectiveness.

Our analysis identified a lower cost per quality adjusted life year gained than the previous analysis by Prosser and colleagues. (2) Its results are similar to those of other models that have examined the cost- effectiveness of statins for primary prevention. (3) Further studies are required to better identify reasons for the observed differences in results.(4)

I agree with Dr. Chelmowski's recommendation that baseline risk of CHD events be considered when measuring quality and developing pay for performance programs for CHD prevention. Recent efforts to develop methods to perform more informative evaluations are promising, but will require improved informatics systems to be feasible for broad application. (5)

Michael Pignone, MD, MPH Associate Professor of Medicine University of North Carolina- Chapel Hill

References:

1. Pignone M, Phillips C, Mulrow C. Use of lipid lowering drugs for primary prevention of coronary heart disease: meta-analysis of randomised trials. BMJ. 2000; 321:983-6.

2. Prosser LA, Stinnett AA, Goldman PA, Williams LW, Hunink MG, Goldman L, Weinstein MC. Cost-effectiveness of cholesterol-lowering therapies according to selected patient characteristics. Ann Intern Med. 2000; 132(10):769-79.

3. Pickin DM, McCabe CJ, Ramsay LE, Payne N, Haq IU, Yeo WW, Jackson PR. Cost effectiveness of HMG-CoA reductase inhibitor (statin) treatment related to the risk of coronary heart disease and cost of drug treatment. Heart. 1999; 82:325-32

4. Pignone M, Saha S, Hoerger T, Lohr KN, Teutsch S, Mandelblatt J.Challenges in systematic reviews of economic analyses. Ann Intern Med. 2005;142(12 Pt 2):1073-9.

5. Rodondi N, Peng T, Karter AJ, Bauer DC, Vittinghoff E, Tang S, Pettitt D, Kerr EA, Selby JV. Therapy modifications in response to poorly controlled hypertension, dyslipidemia, and diabetes mellitus. Ann Intern Med. 2006; 144(7):475-84.

Conflict of Interest:

None declared