Statins may be more cost-effective than stress testing to determine primary CHD prevention in some patients

Treating all intermediate-risk patients with high-potency generic statins to prevent coronary heart disease (CHD) may be more cost-effective than basing treatment on noninvasive stress testing, a new study indicates.

Researchers used a computer-simulated model of CHD in U.S. adults 35 to 84 years of age to perform a cost-effectiveness analysis of the following four strategies for primary prevention:

1. 1. The status quo, which simulated current use of aspirin and statins in the U.S.;
2. 2. Treatment based on the Adult Treatment Panel (ATP III) guidelines, that is, low-potency statins in patients with a low-density lipoprotein cholesterol level of at least 130 mg/dL (≥3.36 mmol/L);
3. 3. “Treat all,” in which all intermediate-risk men and women received statins and all men also received aspirin; and
4. 4. “Test and treat,” in which intermediate-risk men and women received high-potency statins and men also received aspirin only after a positive result on a noninvasive stress test (stress electrocardiography, stress electrocardiography plus a nuclear perfusion scan, or stress echocardiography).

The model projected health care costs, CHD events and quality-adjusted life-years from 2011 to 2040. The study results were published early online Dec. 5 by Circulation.

The model initially included all U.S. men and women who were 45 years of age and 55 years of age, respectively, in 2011 and had a 10% to 20% risk for a CHD event in the next 10 years, per the ATP III guidelines. Additional intermediate-risk men and women 45 and 55 years of age were added to the model each year, while men and women who died or were reclassified as high risk before their next 10-year screening but did not first develop CHD were removed. People who were at intermediate risk and developed CHD were followed until 2040 or until they died, whichever event occurred first.

Overall, the authors found that the “treat all” strategy was most effective and cost the least. In the “test and treat” strategies, stress testing with electrocardiography was the most effective and least expensive method, but was still more expensive than “treat all” unless statins were assumed to cost more than $3.16 per pill and if adherence increased from under 22% to over 75% after testing. Stress testing with electrocardiography could be cost-effective in patients who initially didn't adhere to statin and aspirin treatment if it increased adherence to 5% and could save money if it increased adherence to 13%.

The study used data from published studies to model sensitivity and specificity of noninvasive testing and assumed that all patients who were between 45 and 65 years of age would be physically able to perform a stress test that would yield definitive results, among other limitations. However, the authors concluded that prescribing high-potency generic statins is more cost-effective than basing primary CHD prevention on results of noninvasive stress tests, except in cases where such tests can significantly increase adherence to drug therapy. The authors recommended that these strategies be compared with other and perhaps more cost-effective methods of increasing medication adherence.