Optimizing Statin Treatment for Primary Prevention of Coronary Artery Disease

BACKGROUND: Although treating to lipid targets ("treat to target") is widely recommended for coronary artery disease (CAD) prevention, some have advocated administering fixed doses of statins based on a person's estimated net benefit ("tailored treatment"). OBJECTIVE: To examine how a tailored treatment approach to statin therapy compares with a treat-to-target approach. DESIGN: Simulated model of population-level effects of treat-to-target and tailored treatment approaches to statin therapy. DATA SOURCES: Statin trials from 1994 to 2009 and nationally representative CAD risk factor data. TARGET POPULATION: U.S. persons aged 30 to 75 years with no history of myocardial infarction. TIME HORIZON: Lifetime effects of 5 years of treatment. PERSPECTIVE: Societal and patient. INTERVENTION: Tailored treatment based on a person's 5-year CAD risk (simvastatin, 40 mg, for 5% to 15% CAD risk and atorvastatin, 40 mg, for CAD risk >15%) versus treat-to-target approaches that escalate statin dose per National Cholesterol Education Program NCEP III guidelines (including an intensive approach that advances treatment whenever intensification is optional by NCEP III criteria). OUTCOME MEASURES: Quality-adjusted life-years (QALYs). RESULTS OF BASE-CASE ANALYSIS: Compared with the standard NCEP III approach, the intensive NCEP III approach treated 15 million more persons and saved 570,000 more QALYs over 5 years. The tailored strategy treated a similar number of persons, as did the intensive NCEP III approach, but saved 500,000 more QALYs and treated fewer persons with high-dose statins. RESULTS OF SENSITIVITY ANALYSIS: No circumstances were found in which a treat-to-target approach was preferable to tailored treatment. LIMITATION: Model assumptions were based on available clinical data, which included few persons 75 years or older. CONCLUSION: A tailored treatment strategy prevents more CAD events while treating fewer persons with high-dose statins than low-density lipoprotein cholesterol-based target approaches. Results were robust, even with assumptions favoring a treat-to-target approach. PRIMARY FUNDING SOURCE: Department of Veteran Affairs Health Services Research & Development Service's Quality Enhancement Research Initiative.