Cost-effectiveness of statin therapy for primary prevention of cardiovascular disease based on different LDL-C targets: a modelling study

Abstract Background Low-density lipoprotein cholesterol (LDL-C) targets recommended by major guidelines on primary prevention of cardiovascular disease (CVD) vary substantially across regions. Despite established benefits, statin coverage remains suboptimal, particularly in low- and middle-income countries (LMIC). Purpose To assess the cost-effectiveness of statin therapy for primary prevention of CVD in Chinese, using LDL-C thresholds tailored to predicted CVD risk. Methods We developed a microsimulation model to project the impact of various statin initiation strategies on costs, clinical outcomes and quality-adjusted life years (QALYs) over a 10-year horizon from the healthcare sector perspective. The model simulated nationally representative data from the CHARLS study, comprising adults aged 40-80 who were free of diabetes, had no CVD history, and were statin-naïve (representing an estimated 324. 6 million Chinese). The simulation tracked statin treatment initiation, subsequent CVD events, and mortality (both CVD- and non-CVD-related) based on parameters derived from published literature and a prospective cohort from the CHERRY study. We evaluated eight scenarios by applying different LDL-C thresholds (3. 4 mmol/L, 2. 6 mmol/L, and 1. 8 mmol/L) across three CVD risk categories (low, moderate, and high), including no statin treatment; a uniform strategy (3. 4 mmol/L threshold for all risk groups) ; and modified strategies based on various international guidelines. The primary outcomes included number of CVD events prevented, number needed to treat (NNT) to prevent one CVD event, QALYs gained, and the incremental cost-effectiveness ratios (ICER). Costs and QALYs were discounted at 5% annually. Results All strategies were cost-effective, with ICERs below three times China’s 2023 per-capita GDP (US12, 973). The intensive strategy (3. 4 mmol/L for low-risk, 2. 6 mmol/L for moderate-risk, and 1. 8 mmol/L for high-risk) prevented the most CVD events (6. 81 million) but had the highest incremental cost (US160. 07 billion), and an ICER of US28, 526 per QALY gained. A modified strategy per the 2019 ESC lipid-management guideline could prevent comparable CVD events to the intensive strategy (6. 72 vs 6. 81 million), with a more favourable ICER per QALY gained (US27, 467), while the uniform strategy prevented fewer events (1. 72 million) but required substantially lower investment (incremental cost: US40. 71 billion). A modified strategy per the 2016 ESC lipid-management guideline demonstrated optimal balance with a NNT of 27 to prevent one CVD event and an ICER of US22, 901 per QALY gained. (Figure 1) Conclusion In Chinese adults, a strategy using LDL-C thresholds of 3. 4 mmol/L and 2. 6 mmol/L for moderate- and high-risk adults to guide statin therapy optimally balances clinical effectiveness with cost efficiency. A uniform 3. 4 mmol/L threshold offers benefits in resource-limited settings, supporting tailored statin implementation strategies in LMIC regions.