Key result
ApoB-guided lipid-lowering therapy proves cost-effective over non-HDL-C targeting at ~$30,300 per QALY gained.
Why the study?
The cost-effectiveness of LDL-C, non-HDL-C, and apoB goals for intensifying lipid-lowering therapy in primary prevention has not been established.
Does intensifying lipid-lowering therapy based on apoB or non-HDL-C goals improve cost-effectiveness compared to LDL-C goals in statin-eligible adults for primary prevention?
Does intensifying lipid-lowering therapy based on apoB or non-HDL-C goals improve cost-effectiveness compared to LDL-C goals in statin-eligible adults for primary prevention?
Effect estimate: ICER $30,300 per QALY gained
Using apoB as a target for intensifying lipid-lowering therapy in primary prevention is highly cost-effective compared to traditional LDL-C or non-HDL-C goals.
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“The cost-effectiveness analysis findings by [Luebbe, et al.] have potential clinical implications. Additional evidence in lower-risk populations and data on clinical feasibility will be needed to determine whether this broader strategy should inform future guideline recommendations.”
Simulation supports apoB for cost-effective primary prevention guidance; leaves open real-world validation and prospective trials before adoption.
IMPORTANCE: Apolipoprotein B (apoB) is a superior marker of residual atherosclerotic cardiovascular disease risk in patients treated with lipid-lowering therapy (LLT) compared with low-density lipoprotein cholesterol (LDL-C) and non-high-density lipoprotein cholesterol (non-HDL-C). The cost-effectiveness of LDL-C, non-HDL-C, and apoB goals has not been established. OBJECTIVE: To determine the relative cost-effectiveness of intensifying LLT for primary prevention based on LDL-C, non-HDL-C, and apoB goals. DESIGN, SETTING, AND PARTICIPANTS: This economic evaluation used a computer simulation model to evaluate the cost-effectiveness of intensifying LLT with high-intensity statins or ezetimibe according to LDL-C, non-HDL-C, or apoB goals. A cohort of 250 000 statin-eligible and atherosclerotic cardiovascular disease-free US adults was constructed from 2005 to 2016 National Health and Nutrition Examination Survey participants (N = 4149). Individuals commenced the simulation after lipid screening and received statin therapy based on 2018 American Heart Association/American College of Cardiology guidelines. Model inputs were derived from national survey data, pooled longitudinal cohort studies, and published literature. Uncertainty was explored with traditional and probabilistic sensitivity analysis. EXPOSURES: Lipid-lowering therapy was intensified if individuals did not achieve treated LDL-C level less than 100 mg/dL, non-HDL-C level less than 118 mg/dL, or apoB level less than 78.7 mg/dL. MAIN OUTCOMES AND MEASURES: Lifetime quality-adjusted life-years (QALYs) and costs (in 2025 US dollars), discounted 3.0% annually. The primary outcome was the incremental cost-effectiveness ratio. Strategies were considered cost-effective if they cost less than $120 000 per QALY gained. RESULTS: Compared with an LDL-C goal, 965 QALYs (95% uncertainty interval [UI], -3551 to 5341 QALYs) would be gained with a non-HDL-C goal, alongside a $2.1 million (95% UI, -$94.2 million to $92.0 million) reduction in costs. Compared with a non-HDL-C goal, 1324 QALYs (95% UI, -2602 to 5669 QALYs) would be gained with an apoB goal, alongside a $40.2 million (95% UI, -$43.6 million to $134 million) increase in costs, yielding an incremental cost-effectiveness ratio of $30 300 per QALY gained. At a willingness-to-pay threshold of $120 000 per QALY gained, an apoB goal was optimal in 65% of probabilistic analyses and a non-HDL-C goal was optimal in 25%. The cost of apoB testing was marginal; higher costs reflected longer life expectancy and prolonged preventive treatment. CONCLUSIONS AND RELEVANCE: The results of this computer simulation study suggest that apoB can be used as a cost-effective marker to guide primary prevention LLT and improve population health.
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Luebbe et al. (2026) studied Primary prevention of atherosclerotic cardiovascular disease (n=4,149). Lipid-lowering therapy intensified by apoB goal vs. LDL-C or non-HDL-C goals was evaluated on Incremental cost-effectiveness ratio (ICER $30,300 per QALY gained). Intensifying lipid-lowering therapy based on an apoB goal was cost-effective compared with a non-HDL-C goal, yielding an incremental cost-effectiveness ratio of $30,300 per QALY gained.
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