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Lost therapeutic benefit of delayed LDL-C control in statin treated patients and cost-effectiveness analysis of lipid-lowering intensification

Published:November 24, 2022DOI:https://doi.org/10.1016/j.jval.2022.11.013
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      HIGHLIGHTS

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        Most statin treated patients do not achieve LDL-C therapeutic targets, remaining at high risk of CHD; the lost therapeutic benefit and the economic impact of delaying target achievement is unclear.
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        Delaying lipid-lowering intensification translates into worse health and economic outcomes compared to early and intense lipid lowering for statin treated individuals with uncontrolled LDL-C and no prior CVD.

      ABSTRACT

      Objective

      Attainment of low-density lipoprotein cholesterol (LDL-C) therapeutic goals in statin-treated patients remains suboptimal. We quantified the health-economic impact of delayed lipid-lowering intensification from an Australian healthcare and societal perspective.

      Methods

      A lifetime Markov cohort model (n = 1,000) estimating the impact on coronary heart disease (CHD) of intensifying lipid-lowering treatment in statin-treated patients with uncontrolled LDL-C, at moderate-high risk of CHD with no delay or after a five-year delay, compared to standard of care (no intensification), starting at age 40. Intensification was tested with high-intensity statins or statins+ezetimibe. LDL-C levels were extracted from a primary care cohort. CHD risk was estimated using the Pooled Cohort Equation. The effect of cumulative exposure to LDL-C on CHD risk was derived from Mendelian randomisation data. Outcomes included CHD events, quality-adjusted life years (QALYs), healthcare and productivity costs, and incremental cost-effectiveness ratios (ICER). All outcomes were annually discounted by 5%.

      Results

      Over the lifetime horizon, when compared to standard of care, achieving LDL-C control with no delay with high intensity statins prevented 29 CHD events and yield 30 extra QALYs (ICERs AU$13,205/QALY) versus 22 CHD events and 16 QALYs (ICER AU$20,270/QALY) with a five-year delay. For statins+ezetimibe, no delay prevented 53 CHD events and gave 45 extra QALYs (ICER AU$37,271/QALY) versus 40 CHD events and 29 QALYs (ICER of AU$44,218/QALY) after a five-year delay.

      Conclusions

      Delaying attainment of LDL-C targets translates into lost therapeutic benefit and a waste of resources. Urgent policies are needed to improve LDL-C goal attainment in statin-treated patients.
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