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Kohli-Lynch C, Thanassoulis G, Pencina M, Sehayek D, Pencina K, Moran A, Sniderman AD. The Causal-Benefit Model to Prevent Cardiovascular Events. JACC. ADVANCES 2024; 3:100825. [PMID: 38938840 PMCID: PMC11198721 DOI: 10.1016/j.jacadv.2023.100825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 11/02/2023] [Accepted: 11/28/2023] [Indexed: 06/29/2024]
Abstract
Selecting individuals for preventive lipid-lowering therapy is presently governed by the 10-year risk model. Once a prespecified level of cardiovascular disease risk is equaled or exceeded, individuals become eligible for preventive lipid-lowering therapy. A key limitation of this model is that only a small minority of individuals below the age of 65 years are eligible for therapy. However, just under one-half of all cardiovascular disease events occur below this age. Additionally, in many, the disease that caused their events after 65 years of age developed and progressed before 65 years of age. The causal-benefit model of prevention identifies individuals based both on their risk and the estimated benefit from lowering atherogenic apoB lipoprotein levels. Adopting the causal-benefit model would increase the number of younger subjects eligible for preventive treatment, would increase the total number of cardiovascular disease events prevented at virtually the same number to treat, and would be cost-effective.
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Affiliation(s)
- Ciaran Kohli-Lynch
- Department of Preventive Medicine, Northwestern University, Chicago, Illinois, USA
| | - George Thanassoulis
- Department of Medicine, Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, McGill University Health Centre, Montreal, Quebec, Canada
| | - Michael Pencina
- Department of Medicine, Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, McGill University Health Centre, Montreal, Quebec, Canada
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, DCRI, Durham, North Carolina, USA
| | - Daniel Sehayek
- Department of Medicine, Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, McGill University Health Centre, Montreal, Quebec, Canada
| | - Karol Pencina
- Department of Medicine, Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, McGill University Health Centre, Montreal, Quebec, Canada
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Andrew Moran
- Division of General Medicine, Columbia University Medical Center, New York, New York, USA
| | - Allan D. Sniderman
- Department of Medicine, Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, McGill University Health Centre, Montreal, Quebec, Canada
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Coverdell TC, Sampson M, Zubirán R, Wolska A, Donato LJ, Meeusen JW, Jaffe AS, Remaley AT. An improved method for estimating low LDL-C based on the enhanced Sampson-NIH equation. Lipids Health Dis 2024; 23:43. [PMID: 38331834 PMCID: PMC10851542 DOI: 10.1186/s12944-024-02018-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 01/13/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND The accurate measurement of Low-density lipoprotein cholesterol (LDL-C) is critical in the decision to utilize the new lipid-lowering therapies like PCSK9-inhibitors (PCSK9i) for high-risk cardiovascular disease patients that do not achieve sufficiently low LDL-C on statin therapy. OBJECTIVE To improve the estimation of low LDL-C by developing a new equation that includes apolipoprotein B (apoB) as an independent variable, along with the standard lipid panel test results. METHODS Using β-quantification (BQ) as the reference method, which was performed on a large dyslipidemic population (N = 24,406), the following enhanced Sampson-NIH equation (eS LDL-C) was developed by least-square regression analysis: [Formula: see text] RESULTS: The eS LDL-C equation was the most accurate equation for a broad range of LDL-C values based on regression related parameters and the mean absolute difference (mg/dL) from the BQ reference method (eS LDL-C: 4.51, Sampson-NIH equation [S LDL-C]: 6.07; extended Martin equation [eM LDL-C]: 6.64; Friedewald equation [F LDL-C]: 8.3). It also had the best area-under-the-curve accuracy score by Regression Error Characteristic plots for LDL-C < 100 mg/dL (eS LDL-C: 0.953; S LDL-C: 0.920; eM LDL-C: 0.915; F LDL-C: 0.874) and was the best equation for categorizing patients as being below or above the 70 mg/dL LDL-C treatment threshold for adding new lipid-lowering drugs by kappa score analysis when compared to BQ LDL-C for TG < 800 mg/dL (eS LDL-C: 0.870 (0.853-0.887); S LDL-C:0.763 (0.749-0.776); eM LDL-C:0.706 (0.690-0.722); F LDL-C:0.687 (0.672-0.701). Approximately a third of patients with an F LDL-C < 70 mg/dL had falsely low test results, but about 80% were correctly reclassified as higher (≥ 70 mg/dL) by the eS LDL-C equation, making them potentially eligible for PCSK9i treatment. The M LDL-C and S LDL-C equations had less false low results below 70 mg/dL than the F LDL-C equation but reclassification by the eS LDL-C equation still also increased the net number of patients correctly classified. CONCLUSIONS The use of the eS LDL-C equation as a confirmatory test improves the identification of high-risk cardiovascular disease patients, who could benefit from new lipid-lowering therapies but have falsely low LDL-C, as determined by the standard LDL-C equations used in current practice.
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Affiliation(s)
- Tatiana C Coverdell
- Clinical Center, Department of Laboratory Medicine, National Institutes of Health, Bethesda, MD, USA
| | - Maureen Sampson
- Clinical Center, Department of Laboratory Medicine, National Institutes of Health, Bethesda, MD, USA
| | - Rafael Zubirán
- Lipoprotein Metabolism Laboratory, Translational Vascular Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Anna Wolska
- Lipoprotein Metabolism Laboratory, Translational Vascular Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Leslie J Donato
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Jeff W Meeusen
- Cardiovascular Laboratory Medicine, Mayo Clinic, Rochester, MN, USA
| | - Allan S Jaffe
- Division of Clinical Core Laboratory Services, Mayo Clinic, Rochester, MN, USA
| | - Alan T Remaley
- Lipoprotein Metabolism Laboratory, Translational Vascular Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA.
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Bryan AS, Moran AE, Mobley CM, Derington CG, Rodgers A, Zhang Y, Fontil V, Shea S, Bellows BK. Cost-effectiveness analysis of initial treatment with single-pill combination antihypertensive medications. J Hum Hypertens 2023; 37:985-992. [PMID: 36792728 PMCID: PMC10425570 DOI: 10.1038/s41371-023-00811-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 01/26/2023] [Accepted: 02/03/2023] [Indexed: 02/17/2023]
Abstract
Hypertension guidelines recommend initiating treatment with single pill combination (SPC) antihypertensive medications, but SPCs are used by only one-third of treated hypertensive US adults. This analysis estimated the cost-effectiveness of initial treatment with SPC dual antihypertensive medications compared with usual care monotherapy in hypertensive US adults.The validated BP Control Model-Cardiovascular Disease (CVD) Policy Model simulated initial SPC dual therapy (two half-standard doses in a single pill) compared with initial usual care monotherapy (half-standard dose when baseline systolic BP < 20 mmHg above goal and one standard dose when ≥20 mmHg above goal). Secondary analyses examined equivalent dose monotherapy (one standard dose) and equivalent dose dual therapy as separate pills (two half-standard doses). The primary outcomes were direct healthcare costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER) over 10 years from a US healthcare sector perspective.At 10 years, initial dual drug SPC was projected to yield 0.028 (95%UI 0.008 to 0.051) more QALYs at no greater cost ($73, 95%UI -$1 983 to $1 629) than usual care monotherapy. In secondary analysis, SPC dual therapy was cost-effective vs. equivalent dose monotherapy (ICER $8 000/QALY gained) and equivalent dose dual therapy as separate pills (ICER $57 000/QALY gained). At average drug prices, initiating antihypertensive treatment with SPC dual therapy is more effective at no greater cost than usual care initial monotherapy and has the potential to improve BP control rates and reduce the burden of CVD in the US.
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Leiherer A, Muendlein A, Saely CH, Geiger K, Brandtner EM, Heinzle C, Gaenger S, Mink S, Laaksonen R, Fraunberger P, Drexel H. Coronary Event Risk Test (CERT) as a Risk Predictor for the 10-Year Clinical Outcome of Patients with Peripheral Artery Disease. J Clin Med 2023; 12:6151. [PMID: 37834795 PMCID: PMC10573503 DOI: 10.3390/jcm12196151] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 08/30/2023] [Accepted: 09/21/2023] [Indexed: 10/15/2023] Open
Abstract
(1) Background: Ceramides are a new kind of lipid biomarker and have already been demonstrated to be valuable risk predictors in coronary patients. Patients with peripheral artery disease (PAD) are a population with a worse prognosis and higher mortality risk compared to coronary artery disease (CAD) patients. However, the value of ceramides for risk prediction in PAD patients is still vague, as addressed in the present study. (2)Methods: This observational study included 379 PAD patients. The primary endpoint was all-cause mortality at 10 years of follow-up. A set of ceramides was measured by LC-MS/MS and combined according to the Coronary Event Risk Test (CERT) score, which categorizes patients into one of four risk groups (low risk, moderate risk, high risk, very high risk). (3) Results: Kaplan-Meier survival curves revealed that the overall survival of patients decreased with the increasing risk predicted by the four CERT categories, advancing from low risk to very high risk. Cox regression analysis demonstrated that each one-category increase resulted in a 35% rise in overall mortality risk (HR = 1.35 [1.16-1.58]). Multivariable adjustment, including, among others, age, LDL-cholesterol, type 2 diabetes, and statin treatment before the baseline, did not abrogate this significant association (HR = 1.22 [1.04-1.43]). Moreover, we found that the beneficial effect of statin treatment is significantly stronger in patients with a higher risk, according to CERT. (4) Conclusions: We conclude that the ceramide-based risk score CERT is a strong predictor of the 10-year mortality risk in patients with PAD.
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Affiliation(s)
- Andreas Leiherer
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Academic Teaching Hospital Feldkirch, Carinagasse 47, A-6800 Feldkirch, Austria; (A.M.); (K.G.); (E.-M.B.); (S.G.); (H.D.)
- Private University of the Principality of Liechtenstein, FL-9495 Triesen, Liechtenstein; (S.M.); (P.F.)
- Medical Central Laboratories, A-6800 Feldkirch, Austria
| | - Axel Muendlein
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Academic Teaching Hospital Feldkirch, Carinagasse 47, A-6800 Feldkirch, Austria; (A.M.); (K.G.); (E.-M.B.); (S.G.); (H.D.)
- Private University of the Principality of Liechtenstein, FL-9495 Triesen, Liechtenstein; (S.M.); (P.F.)
| | - Christoph H. Saely
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Academic Teaching Hospital Feldkirch, Carinagasse 47, A-6800 Feldkirch, Austria; (A.M.); (K.G.); (E.-M.B.); (S.G.); (H.D.)
- Private University of the Principality of Liechtenstein, FL-9495 Triesen, Liechtenstein; (S.M.); (P.F.)
- Department of Internal Medicine III, Academic Teaching Hospital Feldkirch, A-6800 Feldkirch, Austria
| | - Kathrin Geiger
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Academic Teaching Hospital Feldkirch, Carinagasse 47, A-6800 Feldkirch, Austria; (A.M.); (K.G.); (E.-M.B.); (S.G.); (H.D.)
- Medical Central Laboratories, A-6800 Feldkirch, Austria
| | - Eva-Maria Brandtner
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Academic Teaching Hospital Feldkirch, Carinagasse 47, A-6800 Feldkirch, Austria; (A.M.); (K.G.); (E.-M.B.); (S.G.); (H.D.)
| | - Christine Heinzle
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Academic Teaching Hospital Feldkirch, Carinagasse 47, A-6800 Feldkirch, Austria; (A.M.); (K.G.); (E.-M.B.); (S.G.); (H.D.)
- Medical Central Laboratories, A-6800 Feldkirch, Austria
| | - Stella Gaenger
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Academic Teaching Hospital Feldkirch, Carinagasse 47, A-6800 Feldkirch, Austria; (A.M.); (K.G.); (E.-M.B.); (S.G.); (H.D.)
| | - Sylvia Mink
- Private University of the Principality of Liechtenstein, FL-9495 Triesen, Liechtenstein; (S.M.); (P.F.)
- Medical Central Laboratories, A-6800 Feldkirch, Austria
| | - Reijo Laaksonen
- Finnish Cardiovascular Research Center, University of Tampere, FI-33014 Tampere, Finland;
- Zora Biosciences, FI-02150 Espoo, Finland
| | - Peter Fraunberger
- Private University of the Principality of Liechtenstein, FL-9495 Triesen, Liechtenstein; (S.M.); (P.F.)
- Medical Central Laboratories, A-6800 Feldkirch, Austria
| | - Heinz Drexel
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Academic Teaching Hospital Feldkirch, Carinagasse 47, A-6800 Feldkirch, Austria; (A.M.); (K.G.); (E.-M.B.); (S.G.); (H.D.)
- Private University of the Principality of Liechtenstein, FL-9495 Triesen, Liechtenstein; (S.M.); (P.F.)
- Vorarlberger Landeskrankenhausbetriebsgesellschaft, Academic Teaching Hospital Feldkirch, A-6800 Feldkirch, Austria
- Drexel University College of Medicine, Philadelphia, PA 19129, USA
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Bryant KB, Rao AS, Cohen LP, DanDan N, Kronish IM, Barai N, Fontil V, Zhang Y, Moran AE, Bellows BK. Effectiveness and Cost-Effectiveness of Team-Based Care for Hypertension: A Meta-Analysis and Simulation Study. Hypertension 2023; 80:1199-1208. [PMID: 36883454 PMCID: PMC10987007 DOI: 10.1161/hypertensionaha.122.20292] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 02/16/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND Team-based care (TBC), a team of ≥2 healthcare professionals working collaboratively toward a shared clinical goal, is a recommended strategy to manage blood pressure (BP). However, the most effective and cost-effective TBC strategy is unknown. METHODS A meta-analysis of clinical trials in US adults (aged ≥20 years) with uncontrolled hypertension (≥140/90 mm Hg) was performed to estimate the systolic BP reduction for TBC strategies versus usual care at 12 months. TBC strategies were stratified by the inclusion of a nonphysician team member who could titrate antihypertensive medications. The validated BP Control Model-Cardiovascular Disease Policy Model was used to project the expected BP reductions out to 10 years and simulate cardiovascular disease events, direct healthcare costs, quality-adjusted life years, and cost-effectiveness of TBC with physician and nonphysician titration. RESULTS Among 19 studies comprising 5993 participants, the 12-month systolic BP change versus usual care was -5.0 (95% CI, -7.9 to -2.2) mm Hg for TBC with physician titration and -10.5 (-16.2 to -4.8) mm Hg for TBC with nonphysician titration. Relative to usual care at 10 years, TBC with nonphysician titration was estimated to cost $95 (95% uncertainty interval, -$563 to $664) more per patient and gain 0.022 (0.003-0.042) quality-adjusted life years, costing $4400/quality-adjusted life year gained. TBC with physician titration was estimated to cost more and gain fewer quality-adjusted life years than TBC with nonphysician titration. CONCLUSIONS TBC with nonphysician titration yields superior hypertension outcomes compared with other strategies and is a cost-effective way to reduce hypertension-related morbidity and mortality in the United States.
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Affiliation(s)
| | - Aditi S. Rao
- Vagelos College of Physician and Surgeons, Columbia University, New York, NY
| | - Laura P. Cohen
- Vagelos College of Physician and Surgeons, Columbia University, New York, NY
| | - Nadine DanDan
- New York-Presbyterian Hospital, Columbia University Medical Center, New York, NY
| | - Ian M. Kronish
- Vagelos College of Physician and Surgeons, Columbia University, New York, NY
| | - Nikita Barai
- Icahn School of Medicine, Mount Sinai, New York, NY
| | - Valy Fontil
- Grossman School of Medicine, New York University, New York, NY
| | - Yiyi Zhang
- Vagelos College of Physician and Surgeons, Columbia University, New York, NY
| | - Andrew E. Moran
- Vagelos College of Physician and Surgeons, Columbia University, New York, NY
| | - Brandon K. Bellows
- Vagelos College of Physician and Surgeons, Columbia University, New York, NY
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Lou Z, Yi SS, Pomeranz J, Suss R, Russo R, Rummo PE, Eom H, Liu J, Zhang Y, Moran AE, Bellows BK, Kong N, Li Y. The Health and Economic Impact of Using a Sugar Sweetened Beverage Tax to Fund Fruit and Vegetable Subsidies in New York City: A Modeling Study. J Urban Health 2023; 100:51-62. [PMID: 36550343 PMCID: PMC9918717 DOI: 10.1007/s11524-022-00699-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/07/2022] [Indexed: 12/24/2022]
Abstract
Low fruit and vegetable (FV) intake and high sugar-sweetened beverage (SSB) consumption are independently associated with an increased risk of developing cardiovascular disease (CVD). Many people in New York City (NYC) have low FV intake and high SSB consumption, partly due to high cost of fresh FVs and low cost of and easy access to SSBs. A potential implementation of an SSB tax and an FV subsidy program could result in substantial public health and economic benefits. We used a validated microsimulation model for predicting CVD events to estimate the health impact and cost-effectiveness of SSB taxes, FV subsidies, and funding FV subsidies with an SSB tax in NYC. Population demographics and health profiles were estimated using data from the NYC Health and Nutrition Examination Survey. Policy effects and price elasticity were derived from recent meta-analyses. We found that funding FV subsidies with an SSB tax was projected to be the most cost-effective policy from the healthcare sector perspective. From the societal perspective, the most cost-effective policy was SSB taxes. All policy scenarios could prevent more CVD events and save more healthcare costs among men compared to women, and among Black vs. White adults. Public health practitioners and policymakers may want to consider adopting this combination of policy actions, while weighing feasibility considerations and other unintended consequences.
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Affiliation(s)
- Zhouyang Lou
- School of Industrial Engineering, Purdue University, West Lafayette, IN, USA
| | - Stella S Yi
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Jennifer Pomeranz
- Department of Public Health Policy and Management, School of Global Public Health, New York University, New York, NY, USA
| | - Rachel Suss
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Rienna Russo
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Pasquale E Rummo
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Heesun Eom
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Junxiu Liu
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Yiyi Zhang
- Division of General Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Andrew E Moran
- Division of General Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Brandon K Bellows
- Division of General Medicine, Columbia University Irving Medical Center, New York, NY, USA.
| | - Nan Kong
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, USA.
| | - Yan Li
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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There is urgent need to treat atherosclerotic cardiovascular disease risk earlier, more intensively, and with greater precision: A review of current practice and recommendations for improved effectiveness. Am J Prev Cardiol 2022; 12:100371. [PMID: 36124049 PMCID: PMC9482082 DOI: 10.1016/j.ajpc.2022.100371] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 07/10/2022] [Accepted: 08/05/2022] [Indexed: 12/12/2022] Open
Abstract
Atherosclerotic cardiovascular disease (ASCVD) is epidemic throughout the world and is etiologic for such acute cardiovascular events as myocardial infarction, ischemic stroke, unstable angina, and death. ASCVD also impacts risk for dementia, chronic kidney disease peripheral arterial disease and mobility, impaired sexual response, and a host of other visceral impairments that adversely impact the quality and rate of progression of aging. The relationship between low-density lipoprotein cholesterol (LDL-C) and risk for ASCVD is one of the most highly established and investigated issues in the entirety of modern medicine. Elevated LDL-C is a necessary condition for atherogenesis induction. Basic scientific investigation, prospective longitudinal cohorts, and randomized clinical trials have all validated this association. Yet despite the enormous number of clinical trials which support the need for reducing the burden of atherogenic lipoprotein in blood, the percentage of high and very high-risk patients who achieve risk stratified LDL-C target reductions is low and has remained low for the last thirty years. Atherosclerosis is a preventable disease. As clinicians, the time has come for us to take primordial and primary prevention more serously. Despite a plethora of therapeutic approaches, the large majority of patients at risk for ASCVD are poorly or inadequately treated, leaving them vulnerable to disease progression, acute cardiovascular events, and poor aging due to loss of function in multiple visceral organs. Herein we discuss the need to greatly intensify efforts to reduce risk, decrease disease burden, and provide more comprehensive and earlier risk assessment to optimally prevent ASCVD and its complications. Evidence is presented to support that treatment should aim for far lower goals in cholesterol management, should take into account many more factors than commonly employed today and should begin significantly earlier in life.
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Razavi AC, Mehta A, Sperling LS. Statin therapy for the primary prevention of cardiovascular disease: Pros. Atherosclerosis 2022; 356:41-45. [PMID: 35945050 DOI: 10.1016/j.atherosclerosis.2022.07.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 07/01/2022] [Accepted: 07/06/2022] [Indexed: 11/28/2022]
Abstract
The initiation of statins for the primary prevention of atherosclerotic cardiovascular disease (ASCVD) remains a debated subject, despite decades worth of clinical trial data demonstrating efficacy, effectiveness, and safety. Statin therapy, in addition to blood pressure-lowering drugs and efforts to reduce cigarette smoking, was a key component of the preventive cardiology renaissance that achieved a dramatic reduction in ASCVD-related mortality from the 1950s to 2010. However, deaths attributable to ASCVD have increased by approximately 13% in recent years, which are in part driven by incomplete treatment of risk factor burden starting in youth. Statins are a cornerstone of preventive cardiology practice, not only due to their lipid-lowering properties, but also in part due to their ability to exert pleiotropic effects that promote atherosclerotic plaque stability which reduces the likelihood of atherothrombotic clinical events. While the benefit of statin therapy undoubtedly depends on the presence and degree of atherosclerotic plaque burden, a broader statin allocation strategy on a population-based level should be considered especially in younger communities that are disproportionately affected by ASCVD risk factors. Thus, the era of precision medicine must be balanced with a pragmatic, cost-effective approach that maximizes ASCVD prevention across the life course. Herein, we examine the pros of statin pharmacotherapy in primary prevention while examining over three decades worth of basic science, translational, and clinical research in the setting of clinical practice guidelines.
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Affiliation(s)
- Alexander C Razavi
- Emory Center for Heart Disease Prevention, Emory University School of Medicine, Atlanta, GA, United States; Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA, United States
| | - Anurag Mehta
- Emory Center for Heart Disease Prevention, Emory University School of Medicine, Atlanta, GA, United States; Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA, United States
| | - Laurence S Sperling
- Emory Center for Heart Disease Prevention, Emory University School of Medicine, Atlanta, GA, United States; Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA, United States.
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Virani SS. Statins and Primary Atherosclerotic Cardiovascular Disease Prevention-What We Know, Where We Need to Go, and Why Are We Not There Already? JAMA Netw Open 2022; 5:e2228538. [PMID: 35997983 DOI: 10.1001/jamanetworkopen.2022.28538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Salim S Virani
- Health Policy, Quality & Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center for Innovations, Houston, Texas
- Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
- Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
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Song K, Tang Z, Song Z, Meng S, Yang X, Guo H, Zhu Y, Wang X. Hyaluronic Acid-Functionalized Mesoporous Silica Nanoparticles Loading Simvastatin for Targeted Therapy of Atherosclerosis. Pharmaceutics 2022; 14:pharmaceutics14061265. [PMID: 35745836 PMCID: PMC9227583 DOI: 10.3390/pharmaceutics14061265] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/08/2022] [Accepted: 06/10/2022] [Indexed: 11/16/2022] Open
Abstract
Atherosclerosis (AS) constitutes a major threat to human health, yet most current therapeutics are hindered in achieving desirable clinical outcomes by low bioavailability or serious side effects. Herein, we constructed an enzyme-responsive and macrophage-targeting drug delivery system (SIM@HA-MSN) which can potentially modulate the microenvironment of the atherosclerotic plaques characterized by excessive inflammation and overexpression of hyaluronidase (HAase) for precise AS treatment. More specifically, mesoporous silica nanoparticles (MSNs) were loaded with a lipid-lowering drug simvastatin (SIM) and further gated with hyaluronic acid (HA) coating, which endowed the nanosystem with HAase responsiveness and targetability to inflammatory macrophages. Our results showed that a high loading efficiency (>20%) and excellent enzyme-responsive release of SIM were simultaneously achieved for the first time by silica-based nanocarriers through formulation optimizations. Moreover, in vitro experiments confirmed that SIM@HA-MSN possessed robust targeting, anti-inflammatory, and anti-foaming effects, along with low cytotoxicity and excellent hemocompatibility. In addition, preliminary animal experiments demonstrated the as-established nanosystem had a long plasma-retention time and good biocompatibility in vivo. Taken together, SIM@HA-MSN with HA playing triple roles including gatekeeping, lesion-targeting, and long-circulating holds great potential for the management of atherosclerosis.
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Affiliation(s)
- Kechen Song
- School of Pharmacy and State Key Laboratory of Quality Research in Chinese Medicines, Macau University of Science and Technology, Taipa 999078, Macau, China; (K.S.); (Z.T.); (Z.S.); (S.M.); (X.Y.); (Y.Z.)
| | - Zhuang Tang
- School of Pharmacy and State Key Laboratory of Quality Research in Chinese Medicines, Macau University of Science and Technology, Taipa 999078, Macau, China; (K.S.); (Z.T.); (Z.S.); (S.M.); (X.Y.); (Y.Z.)
| | - Zhiling Song
- School of Pharmacy and State Key Laboratory of Quality Research in Chinese Medicines, Macau University of Science and Technology, Taipa 999078, Macau, China; (K.S.); (Z.T.); (Z.S.); (S.M.); (X.Y.); (Y.Z.)
| | - Shiyu Meng
- School of Pharmacy and State Key Laboratory of Quality Research in Chinese Medicines, Macau University of Science and Technology, Taipa 999078, Macau, China; (K.S.); (Z.T.); (Z.S.); (S.M.); (X.Y.); (Y.Z.)
| | - Xiaoxue Yang
- School of Pharmacy and State Key Laboratory of Quality Research in Chinese Medicines, Macau University of Science and Technology, Taipa 999078, Macau, China; (K.S.); (Z.T.); (Z.S.); (S.M.); (X.Y.); (Y.Z.)
| | - Hui Guo
- School of Chemical Engineering and Technology, Sun Yat-Sen University, Zhuhai 519082, China
- Correspondence: (H.G.); (X.W.)
| | - Yizhun Zhu
- School of Pharmacy and State Key Laboratory of Quality Research in Chinese Medicines, Macau University of Science and Technology, Taipa 999078, Macau, China; (K.S.); (Z.T.); (Z.S.); (S.M.); (X.Y.); (Y.Z.)
| | - Xiaolin Wang
- School of Pharmacy and State Key Laboratory of Quality Research in Chinese Medicines, Macau University of Science and Technology, Taipa 999078, Macau, China; (K.S.); (Z.T.); (Z.S.); (S.M.); (X.Y.); (Y.Z.)
- Correspondence: (H.G.); (X.W.)
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12
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Green MB, Shimbo D, Schwartz JE, Bress AP, King JB, Muntner P, Sheppard JP, McManus RJ, Kohli-Lynch CN, Zhang Y, Shea S, Moran AE, Bellows BK. Cost-Effectiveness of Masked Hypertension Screening and Treatment in US Adults With Suspected Masked Hypertension: A Simulation Study. Am J Hypertens 2022; 35:752-762. [PMID: 35665802 PMCID: PMC9340638 DOI: 10.1093/ajh/hpac071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 04/25/2022] [Accepted: 06/01/2022] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Recent US blood pressure (BP) guidelines recommend using ambulatory BP monitoring (ABPM) or home BP monitoring (HBPM) to screen adults for masked hypertension. However, limited evidence exists of the expected long-term effects of screening for and treating masked hypertension. METHODS We estimated the lifetime health and economic outcomes of screening for and treating masked hypertension using the Cardiovascular Disease (CVD) Policy Model, a validated microsimulation model. We simulated a cohort of 100,000 US adults aged ≥20 years with suspected masked hypertension (i.e., office BP 120-129/<80 mm Hg, not taking antihypertensive medications, without CVD history). We compared usual care only (i.e., no screening), usual care plus ABPM, and usual care plus HBPM. We projected total direct healthcare costs (2021 USD), quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios. Future costs and QALYs were discounted 3% annually. Secondary outcomes included CVD events and serious adverse events. RESULTS Relative to usual care, adding masked hypertension screening and treatment with ABPM and HBPM was projected to prevent 14.3 and 20.5 CVD events per 100,000 person-years, increase the proportion experiencing any treatment-related serious adverse events by 2.7 and 5.1 percentage points, and increase mean total costs by $1,076 and $1,046, respectively. Compared with usual care, adding ABPM was estimated to cost $85,164/QALY gained. HBPM resulted in lower QALYs than usual care due to increased treatment-related adverse events and pill-taking disutility. CONCLUSIONS The results from our simulation study suggest screening with ABPM and treating masked hypertension is cost-effective in US adults with suspected masked hypertension.
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Affiliation(s)
- Matthew B Green
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Daichi Shimbo
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Joseph E Schwartz
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA,Department of Psychiatry and Behavioral Health, Stony Brook University, Stony Brook, New York, USA
| | - Adam P Bress
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, USA
| | - Jordan B King
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, USA
| | - Paul Muntner
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - James P Sheppard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ciaran N Kohli-Lynch
- Center for Health Services and Outcomes Research, Institute of Public Health and Medicine, Northwestern Feinberg School of Medicine, Northwestern University, Chicago, Illinois,USA
| | - Yiyi Zhang
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Steven Shea
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Andrew E Moran
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
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13
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Aguiar C. Low-density lipoprotein cholesterol lowering in the comfort zone and the benefits of stepping out. Rev Port Cardiol 2022; 41:689-691. [DOI: 10.1016/j.repc.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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14
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Kohli-Lynch CN, Lewsey J, Boyd KA, French DD, Jordan N, Moran AE, Sattar N, Preiss D, Briggs AH. Beyond Ten-Year Risk: A Cost-Effectiveness Analysis of Statins for the Primary Prevention of Cardiovascular Disease. Circulation 2022; 145:1312-1323. [PMID: 35249370 PMCID: PMC9022692 DOI: 10.1161/circulationaha.121.057631] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Cholesterol guidelines typically prioritize primary prevention statin therapy on the basis of 10-year risk of cardiovascular disease. The advent of generic pricing may justify expansion of statin eligibility. Moreover, 10-year risk may not be the optimal approach for statin prioritization. We estimated the cost-effectiveness of expanding preventive statin eligibility and evaluated novel approaches to prioritization from a Scottish health sector perspective.
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Affiliation(s)
- Ciaran N Kohli-Lynch
- Center for Health Services and Outcomes Research, Northwestern University, Chicago, Illinois; Health Economics and Health Technology Assessment, University of Glasgow, Glasgow, United Kingdom
| | - James Lewsey
- Health Economics and Health Technology Assessment, University of Glasgow, Glasgow, United Kingdom
| | - Kathleen A Boyd
- Health Economics and Health Technology Assessment, University of Glasgow, Glasgow, United Kingdom
| | - Dustin D French
- Center for Health Services and Outcomes Research, Northwestern University, Chicago, Illinois; Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, Hines, Chicago, Illinois; Department of Ophthalmology and Medical Social Science, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Neil Jordan
- Center for Health Services and Outcomes Research, Northwestern University, Chicago, Illinois; Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, Hines, Chicago, Illinois; Departments of Psychiatry & Behavioral Sciences and Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Andrew E Moran
- Division of General Medicine, Columbia University Irving Medical Center, New York City, New York
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - David Preiss
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Andrew H Briggs
- Health Economics and Health Technology Assessment, University of Glasgow, Glasgow, United Kingdom; Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
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15
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Xu Y, Greene TH, Bress AP, Sauer BC, Bellows BK, Zhang Y, Weintraub WS, Moran AE, Shen J. Estimating the optimal individualized treatment rule from a cost-effectiveness perspective. Biometrics 2022; 78:337-351. [PMID: 33215693 PMCID: PMC8134511 DOI: 10.1111/biom.13406] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 10/30/2020] [Accepted: 11/06/2020] [Indexed: 11/27/2022]
Abstract
Optimal individualized treatment rules (ITRs) provide customized treatment recommendations based on subject characteristics to maximize clinical benefit in accordance with the objectives in precision medicine. As a result, there is growing interest in developing statistical tools for estimating optimal ITRs in evidence-based research. In health economic perspectives, policy makers consider the tradeoff between health gains and incremental costs of interventions to set priorities and allocate resources. However, most work on ITRs has focused on maximizing the effectiveness of treatment without considering costs. In this paper, we jointly consider the impact of effectiveness and cost on treatment decisions and define ITRs under a composite-outcome setting, so that we identify the most cost-effective ITR that accounts for individual-level heterogeneity through direct optimization. In particular, we propose a decision-tree-based statistical learning algorithm that uses a net-monetary-benefit-based reward to provide nonparametric estimations of the optimal ITR. We provide several approaches to estimating the reward underlying the ITR as a function of subject characteristics. We present the strengths and weaknesses of each approach and provide practical guidelines by comparing their performance in simulation studies. We illustrate the top-performing approach from our simulations by evaluating the projected 15-year personalized cost-effectiveness of the intensive blood pressure control of the Systolic Blood Pressure Intervention Trial (SPRINT) study.
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Affiliation(s)
- Yizhe Xu
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
| | - Tom H. Greene
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah,Department of Internal Medicine, University of Utah, Salt Lake City, Utah,Department of Family and Preventive Medicine, University of Utah, Salt Lake City, Utah
| | - Adam P. Bress
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
| | - Brian C. Sauer
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah,Department of Family and Preventive Medicine, University of Utah, Salt Lake City, Utah,Salt Lake City Veterans Affairs Medical Center, Salt Lake City, Utah
| | - Brandon K. Bellows
- Department of Medicine, Columbia University Medical Center, New York, New York
| | - Yue Zhang
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah,Department of Internal Medicine, University of Utah, Salt Lake City, Utah,Department of Family and Preventive Medicine, University of Utah, Salt Lake City, Utah
| | | | - Andrew E. Moran
- Department of Medicine, Columbia University Medical Center, New York, New York
| | - Jincheng Shen
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah,Department of Internal Medicine, University of Utah, Salt Lake City, Utah,Department of Family and Preventive Medicine, University of Utah, Salt Lake City, Utah
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16
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Lauren BN, Lim F, Krikhely A, Taveras EM, Woo Baidal JA, Bellows BK, Hur C. Estimated Cost-effectiveness of Medical Therapy, Sleeve Gastrectomy, and Gastric Bypass in Patients With Severe Obesity and Type 2 Diabetes. JAMA Netw Open 2022; 5:e2148317. [PMID: 35157054 PMCID: PMC8845022 DOI: 10.1001/jamanetworkopen.2021.48317] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 12/21/2021] [Indexed: 12/16/2022] Open
Abstract
Importance Bariatric surgery is recommended for patients with severe obesity (body mass index ≥40) and type 2 diabetes (T2D). However, the most cost-effective treatment remains unclear and may depend on the patient's T2D severity. Objective To estimate the cost-effectiveness of medical therapy, sleeve gastrectomy (SG), and Roux-en-Y gastric bypass (RYGB) among patients with severe obesity and T2D, stratified by T2D severity. Design, Setting, and Participants This economic evaluation used a microsimulation model to project health and cost outcomes of medical therapy, SG, and RYGB over 5 years. Time horizons varied between 10 and 30 years in sensitivity analyses. Model inputs were derived from clinical trials, large cohort studies, national databases, and published literature. Probabilistic sampling of model inputs accounted for parameter uncertainty. Estimates of US adults with severe obesity and T2D were derived from the National Health and Nutrition Examination Survey. Data analysis was performed from January 2020 to August 2021. Exposures Medical therapy, SG, and RYGB. Main Outcomes and Measures Quality-adjusted life-years (QALYs), costs (in 2020 US dollars), and incremental cost-effectiveness ratios (ICERs) were projected, with future cost and QALYs discounted 3.0% annually. A strategy was deemed cost-effective if the ICER was less than $100 000 per QALY. The preferred strategy resulted in the greatest number of QALYs gained while being cost-effective. Results The model simulated 1000 cohorts of 10 000 patients, of whom 16% had mild T2D, 56% had moderate T2D, and 28% had severe T2D at baseline. The mean age of simulated patients was 54.6 years (95% CI, 54.2-55.0 years), 61.6% (95% CI, 60.1%-63.4%) were female, and 65.1% (95% CI, 63.6%-66.7%) were non-Hispanic White. Compared with medical therapy over 5 years, RYGB was associated with the most QALYs gained in the overall population (mean, 0.44 QALY; 95% CI, 0.21-0.86 QALY) and when stratified by baseline T2D severity: mild (mean, 0.59 QALY; 95% CI, 0.35-0.98 QALY), moderate (mean, 0.50 QALY; 95% CI, 0.25-0.88 QALY), and severe (mean, 0.30 QALY; 95% CI, 0.07-0.79 QALY). RYGB was the preferred strategy in the overall population (ICER, $46 877 per QALY; 83.0% probability preferred) and when stratified by baseline T2D severity: mild (ICER, $36 479 per QALY; 73.7% probability preferred), moderate (ICER, $37 056 per QALY; 85.6% probability preferred), and severe (ICER, $98 940 per QALY; 40.2% probability preferred). The cost-effectiveness of RYGB improved over a longer time horizon. Conclusions and Relevance These findings suggest that the effectiveness and cost-effectiveness of bariatric surgery vary by baseline severity of T2D. Over a 5-year time horizon, RYGB is projected to be the preferred treatment strategy for patients with severe obesity regardless of baseline T2D severity.
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Affiliation(s)
- Brianna N. Lauren
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Francesca Lim
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Abraham Krikhely
- Department of Surgery, Columbia University Irving Medical Center, New York, New York
| | - Elsie M. Taveras
- Division of General Academic Pediatrics, Massachusetts General Hospital, Boston
| | | | - Brandon K. Bellows
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Chin Hur
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
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17
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Kohli-Lynch CN, Bellows BK, Zhang Y, Spring B, Kazi DS, Pletcher MJ, Vittinghoff E, Allen NB, Moran AE. Cost-Effectiveness of Lipid-Lowering Treatments in Young Adults. J Am Coll Cardiol 2021; 78:1954-1964. [PMID: 34763772 DOI: 10.1016/j.jacc.2021.08.065] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 08/09/2021] [Accepted: 08/24/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Raised low-density lipoprotein cholesterol (LDL-C) in young adulthood (aged 18-39 years) is associated with atherosclerotic cardiovascular disease (ASCVD) later in life. Most young adults with elevated LDL-C do not currently receive lipid-lowering treatment. OBJECTIVES This study aimed to estimate the prevalence of elevated LDL-C in ASCVD-free U.S. young adults and the cost-effectiveness of lipid-lowering strategies for raised LDL-C in young adulthood compared with standard care. METHODS The prevalence of raised LDL-C was examined in the U.S. National Health and Nutrition Examination Survey. The CVD Policy Model projected lifetime quality-adjusted life years (QALYs), health care costs, and incremental cost-effectiveness ratios (ICERs) for lipid-lowering strategies. Standard care was statin treatment for adults aged ≥40 years based on LDL-C, ASCVD risk, or diabetes plus young adults with LDL-C ≥190 mg/dL. Lipid lowering incremental to standard care with moderate-intensity statins or intensive lifestyle interventions was simulated starting when young adult LDL-C was either ≥160 mg/dL or ≥130 mg/dL. RESULTS Approximately 27% of ASCVD-free young adults have LDL-C of ≥130 mg/dL, and 9% have LDL-C of ≥160 mg/dL. The model projected that young adult lipid lowering with statins or lifestyle interventions would prevent lifetime ASCVD events and increase QALYs compared with standard care. ICERs were US$31,000/QALY for statins in young adult men with LDL-C of ≥130 mg/dL and US$106,000/QALY for statins in young adult women with LDL-C of ≥130 mg/dL. Intensive lifestyle intervention was more costly and less effective than statin therapy. CONCLUSIONS Statin treatment for LDL-C of ≥130 mg/dL is highly cost-effective in young adult men and intermediately cost-effective in young adult women.
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Affiliation(s)
- Ciaran N Kohli-Lynch
- Division of General Medicine, Columbia University Irving Medical Center, New York, New York, USA; Center for Health Services and Outcomes Research, Northwestern University, Chicago, Illinois, USA; Health Economics and Health Technology Assessment, University of Glasgow, Glasgow, United Kingdom
| | - Brandon K Bellows
- Division of General Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Yiyi Zhang
- Division of General Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Bonnie Spring
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Dhruv S Kazi
- Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Mark J Pletcher
- Department of Epidemiology and Biostatistics, University of California-San Francisco School of Medicine, San Francisco, California, USA
| | - Eric Vittinghoff
- Department of Epidemiology and Biostatistics, University of California-San Francisco School of Medicine, San Francisco, California, USA
| | - Norrina B Allen
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Andrew E Moran
- Division of General Medicine, Columbia University Irving Medical Center, New York, New York, USA.
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18
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Brunette CA, Dong OM, Vassy JL, Danowski ME, Alexander N, Antwi AA, Christensen KD. A Cost-Consequence Analysis of Preemptive SLCO1B1 Testing for Statin Myopathy Risk Compared to Usual Care. J Pers Med 2021; 11:1123. [PMID: 34834475 PMCID: PMC8624003 DOI: 10.3390/jpm11111123] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 10/27/2021] [Accepted: 10/29/2021] [Indexed: 11/16/2022] Open
Abstract
There is a well-validated association between SLCO1B1 (rs4149056) and statin-associated muscle symptoms (SAMS). Preemptive SLCO1B1 pharmacogenetic (PGx) testing may diminish the incidence of SAMS by identifying individuals with increased genetic risk before statin initiation. Despite its potential clinical application, the cost implications of SLCO1B1 testing are largely unknown. We conducted a cost-consequence analysis of preemptive SLCO1B1 testing (PGx+) versus usual care (PGx-) among Veteran patients enrolled in the Integrating Pharmacogenetics in Clinical Care (I-PICC) Study. The assessment was conducted using a health system perspective and 12-month time horizon. Incremental costs of SLCO1B1 testing and downstream medical care were estimated using data from the U.S. Department of Veterans Affairs' Managerial Cost Accounting System. A decision analytic model was also developed to model 1-month cost and SAMS-related outcomes in a hypothetical cohort of 10,000 Veteran patients, where all patients were initiated on simvastatin. Over 12 months, 13.5% of PGx+ (26/193) and 11.2% of PGx- (24/215) participants in the I-PICC Study were prescribed Clinical Pharmacogenetics Implementation Consortium (CPIC) guideline-concordant statins (Δ2.9%, 95% CI -4.0% to 10.0%). Differences in mean per-patient costs for lipid therapy prescriptions, including statins, for PGx+ compared to PGx- participants were not statistically significant (Δ USD 9.53, 95% CI -0.86 to 22.80 USD). Differences in per-patient costs attributable to the intervention, including PGx testing, lipid-lowering prescriptions, SAMS, laboratory and imaging expenses, and primary care and cardiology services, were also non-significant (Δ- USD 1004, 95% CI -2684 to 1009 USD). In the hypothetical cohort, SLCO1B1-informed statin therapy averted 109 myalgias and 3 myopathies at 1-month follow up. Fewer statin discontinuations (78 vs. 109) were also observed, but the SLCO1B1 testing strategy was 96 USD more costly per patient compared to no testing (124 vs. 28 USD). The implementation of SLCO1B1 testing resulted in small, non-significant increases in the proportion of patients receiving CPIC-concordant statin prescriptions within a real-world primary care context, diminished the incidence of SAMS, and reduced statin discontinuations in a hypothetical cohort of 10,000 patients. Despite these effects, SLCO1B1 testing administered as a standalone test did not result in lower per-patient health care costs at 1 month or over 1 year of treatment. The inclusion of SLCO1B1, among other well-validated pharmacogenes, into preemptive panel-based testing strategies may provide a better balance of clinical benefit and cost.
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Affiliation(s)
- Charles A. Brunette
- Veterans Affairs Boston Healthcare System, Boston, MA 02130, USA; (J.L.V.); (M.E.D.); (N.A.); (A.A.A.)
| | - Olivia M. Dong
- Duke Center for Applied Genomics & Precision Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC 27705, USA;
- Durham VA Health Care System, Durham, NC 27705, USA
| | - Jason L. Vassy
- Veterans Affairs Boston Healthcare System, Boston, MA 02130, USA; (J.L.V.); (M.E.D.); (N.A.); (A.A.A.)
- Department of Medicine, Harvard Medical School, Boston, MA 02215, USA;
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, MA 02115, USA
- Population Precision Health, Ariadne Labs, Boston, MA 02215, USA
| | - Morgan E. Danowski
- Veterans Affairs Boston Healthcare System, Boston, MA 02130, USA; (J.L.V.); (M.E.D.); (N.A.); (A.A.A.)
| | - Nicholas Alexander
- Veterans Affairs Boston Healthcare System, Boston, MA 02130, USA; (J.L.V.); (M.E.D.); (N.A.); (A.A.A.)
| | - Ashley A. Antwi
- Veterans Affairs Boston Healthcare System, Boston, MA 02130, USA; (J.L.V.); (M.E.D.); (N.A.); (A.A.A.)
| | - Kurt D. Christensen
- Department of Medicine, Harvard Medical School, Boston, MA 02215, USA;
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, MA 02215, USA
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19
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Bryant KB, Moran AE, Kazi DS, Zhang Y, Penko J, Ruiz-Negrón N, Coxson P, Blyler CA, Lynch K, Cohen LP, Tajeu GS, Fontil V, Moy NB, Ebinger JE, Rader F, Bibbins-Domingo K, Bellows BK. Cost-Effectiveness of Hypertension Treatment by Pharmacists in Black Barbershops. Circulation 2021; 143:2384-2394. [PMID: 33855861 PMCID: PMC8206005 DOI: 10.1161/circulationaha.120.051683] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND In LABBPS (Los Angeles Barbershop Blood Pressure Study), pharmacist-led hypertension care in Los Angeles County Black-owned barbershops significantly improved blood pressure control in non-Hispanic Black men with uncontrolled hypertension at baseline. In this analysis, 10-year health outcomes and health care costs of 1 year of the LABBPS intervention versus control are projected. METHODS A discrete event simulation of hypertension care processes projected blood pressure, medication-related adverse events, fatal and nonfatal cardiovascular disease events, and noncardiovascular disease death in LABBPS participants. Program costs, total direct health care costs (2019 US dollars), and quality-adjusted life-years (QALYs) were estimated for the LABBPS intervention and control arms from a health care sector perspective over a 10-year horizon. Future costs and QALYs were discounted 3% annually. High and intermediate cost-effectiveness thresholds were defined as <$50 000 and <$150 000 per QALY gained, respectively. RESULTS At 10 years, the intervention was projected to cost an average of $2356 (95% uncertainty interval, -$264 to $4611) more per participant than the control arm and gain 0.06 (95% uncertainty interval, 0.01-0.10) QALYs. The LABBPS intervention was highly cost-effective, with a mean cost of $42 717 per QALY gained (58% probability of being highly and 96% of being at least intermediately cost-effective). Exclusive use of generic drugs improved the cost-effectiveness to $17 162 per QALY gained. The LABBPS intervention would be only intermediately cost-effective if pharmacists were less likely to intensify antihypertensive medications when systolic blood pressure was ≥150 mm Hg or if pharmacist weekly time driving to barbershops increased. CONCLUSIONS Hypertension care delivered by clinical pharmacists in Black barbershops is a highly cost-effective way to improve blood pressure control in Black men.
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Affiliation(s)
- Kelsey B. Bryant
- Columbia University, Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Andrew E. Moran
- Columbia University, Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Dhruv S. Kazi
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Yiyi Zhang
- Columbia University, Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Joanne Penko
- University of California San Francisco, School of Medicine, San Francisco, CA, USA
| | | | - Pamela Coxson
- University of California San Francisco, School of Medicine, San Francisco, CA, USA
| | - Ciantel A. Blyler
- Smidt Heart Institute, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, USA
| | - Kathleen Lynch
- Providence Saint John’s Health Center, John Wayne Cancer Institute, Santa Monica, CA, USA
| | - Laura P. Cohen
- Columbia University, Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Gabriel S. Tajeu
- Temple University, College of Public Health, Philadelphia, PA, USA
| | - Valy Fontil
- University of California San Francisco, School of Medicine, San Francisco, CA, USA
| | - Norma B. Moy
- Smidt Heart Institute, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, USA
| | - Joseph E. Ebinger
- Smidt Heart Institute, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, USA
| | - Florian Rader
- Smidt Heart Institute, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, USA
| | | | - Brandon K. Bellows
- Columbia University, Vagelos College of Physicians and Surgeons, New York, NY, USA
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Morey JR, Jiang S, Klein S, Max W, Masharani U, Fleischmann KE, Hunink MGM, Ferket BS. Estimating Long-Term Health Utility Scores and Expenditures for Cardiovascular Disease From the Medical Expenditure Panel Survey. Circ Cardiovasc Qual Outcomes 2021; 14:e006769. [PMID: 33761758 DOI: 10.1161/circoutcomes.120.006769] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Long-term health utility scores and costs used in cost-effectiveness analyses of cardiovascular disease prevention and management can be inconsistent, outdated, or invalid for the diverse population of the United States. Our aim was to develop a user friendly, standardized, publicly available code and catalog to derive more valid long-term values for health utility and expenditures following cardiovascular disease events. METHODS Individual-level Short Form-12 version 2 health-related quality of life and expenditure data were obtained from the pooled 2011 to 2016 Medical Expenditure Panel Surveys. We developed code using the R programming language to estimate preference-weighted Short Form-6D utility scores from the Short Form-12 for quality-adjusted life year calculations and predict annual health care expenditures. Result predictors included cardiovascular disease diagnosis (myocardial infarction, ischemic stroke, heart failure, cardiac dysrhythmias, angina pectoris, and peripheral artery disease), sociodemographic factors, and comorbidity variables. RESULTS The cardiovascular disease diagnoses with the lowest utility scores were heart failure (0.635 [95% CI, 0.615-0.655]), angina pectoris (0.649 [95% CI, 0.630-0.667]), and ischemic stroke (0.649 [95% CI, 0.635-0.663]). The highest annual expenditures were for heart failure ($20 764 [95% CI, $17 500-$24 027]), angina pectoris ($18 428 [95% CI, $16 102-$20 754]), and ischemic stroke ($16 925 [95% CI, $15 672-$20 616]). CONCLUSIONS The developed code and catalog may improve the quality and comparability of cost-effectiveness analyses by providing standardized methods for extracting long-term health utility scores and expenditures from Medical Expenditure Panel Survey data, which are more current and representative of the US population than previous sources.
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Affiliation(s)
- Jacob R Morey
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY (J.R.M., B.S.F.)
| | - Shangqing Jiang
- The Comparative Health Outcomes, Policy and Economics (CHOICE) Institute, University of Washington, Seattle (S.J.)
| | - Sharon Klein
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, East Garden City, NY (S.K.)
| | - Wendy Max
- Institute for Health and Aging and Department of Social and Behavioral Sciences (W.M.), University of California, San Francisco
| | - Umesh Masharani
- Department of Medicine (U.M., K.E.F.), University of California, San Francisco
| | | | - M G Myriam Hunink
- Departments of Epidemiology and Radiology, Erasmus MC, Rotterdam, the Netherlands (M.G.M.H.).,Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA (M.G.M.H.)
| | - Bart S Ferket
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY (J.R.M., B.S.F.)
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21
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Jung Y, Frisvold D, Dogan T, Dogan M, Philibert R. Cost-utility analysis of an integrated genetic/epigenetic test for assessing risk for coronary heart disease. Epigenomics 2021; 13:531-547. [PMID: 33625255 DOI: 10.2217/epi-2021-0021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Aim: New epigenetically based methods for assessing risk for coronary heart disease may be more sensitive but are generally more costly than current methods. To understand their potential impact on healthcare spending, we conducted a cost-utility analysis. Methods: We compared costs using the new Epi + Gen CHD™ test with those of existing tests using a cohort Markov simulation model. Results: We found that use of the new test was associated with both better survival and highly competitive negative incremental cost-effectiveness ratios ranging from -$42,000 to -$8000 per quality-adjusted life year for models with and without a secondary test. Conclusion: The new integrated genetic/epigenetic test will save money and lives under most real-world scenarios. Similar advantages may be seen for other epigenetic tests.
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Affiliation(s)
- Younsoo Jung
- Cardio Diagnostics Inc., Coralville, IA 52241, USA
| | - David Frisvold
- Department of Economics, University of Iowa, Iowa City, IA 52242, USA
| | - Timur Dogan
- Cardio Diagnostics Inc., Coralville, IA 52241, USA
| | | | - Rob Philibert
- Cardio Diagnostics Inc., Coralville, IA 52241, USA.,Department of Psychiatry, University of Iowa, Iowa City, IA 52242, USA
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22
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Venkataraman P, Kawakami H, Huynh Q, Mitchell G, Nicholls SJ, Stanton T, Tonkin A, Watts GF, Marwick TH. Cost-Effectiveness of Coronary Artery Calcium Scoring in People With a Family History of Coronary Disease. JACC Cardiovasc Imaging 2021; 14:1206-1217. [PMID: 33454262 DOI: 10.1016/j.jcmg.2020.11.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 10/28/2020] [Accepted: 11/03/2020] [Indexed: 01/13/2023]
Abstract
OBJECTIVES To assess the cost effectiveness of coronary artery calcium (CAC) compared with traditional risk factor-based prediction alone in those with an family history of premature coronary artery disease (FHCAD). BACKGROUND The use of CAC scoring to guide primary prevention statin therapy in those with a FHCAD is inconsistently recommended in guidelines, and usually not reimbursed by insurance. METHODS A microsimulation model was constructed in TreeAge Healthcare Pro using data from 1,083 participants in the CAUGHT-CAD (Coronary Artery Calcium Score: Use to Guide Management of HerediTary Coronary Artery Disease) trial. Outcomes assessed were quality-adjusted life years (QALYs): cost-effectiveness was assessed over a 15-year time horizon from the perspective of the US health care sector using real-world statin prescribing, accounting for the effect of knowledge of subclinical disease on adherence to guideline-directed therapies. Costs were assessed in 2020 USD, with discounting undertaken at 3%. RESULTS Statins were indicated in 45% of the cohort using the CAC strategy and 27% using American College of Cardiology/American Heart Association (2019) treatment strategies. Compared with applying a statin treatment threshold of 7.5%, the CAC strategy was more costly ($145) and more effective (0.0097 QALY) with an incremental cost-effective ratio (ICER) of $15,014/QALY. CAC ICER was driven by CAC acquisition and statin prescription cost and improved with certain patient subgroups: male, age >60 years, and 10-year risk pooled cohort equation risk ≥7.5%. CAC scanning of low-risk patients (10-year risk <5%) or those 40 to 50 years of age was not cost-effective. CONCLUSIONS Systematic CAC screening and treatment of those with FHCAD and subclinical disease was more cost-effective than management using statin treatment thresholds, in the US health care system.
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Affiliation(s)
- Prasanna Venkataraman
- Baker Heart and Diabetes Research Institute, Melbourne, Australia; Monash University, Melbourne, Australia
| | - Hiroshi Kawakami
- Baker Heart and Diabetes Research Institute, Melbourne, Australia
| | - Quan Huynh
- Baker Heart and Diabetes Research Institute, Melbourne, Australia
| | | | | | - Tony Stanton
- The University of Queensland, Brisbane, Australia
| | | | - Gerald F Watts
- Lipid Disorders Clinic, Department of Cardiology, Royal Perth Hospital, School of Medicine, University of Western Australia, Perth, Australia
| | - Thomas H Marwick
- Baker Heart and Diabetes Research Institute, Melbourne, Australia; Monash University, Melbourne, Australia.
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23
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Karády J, Mayrhofer T, Ivanov A, Foldyna B, Lu MT, Ferencik M, Pursnani A, Salerno M, Udelson JE, Mark DB, Douglas PS, Hoffmann U. Cost-effectiveness Analysis of Anatomic vs Functional Index Testing in Patients With Low-Risk Stable Chest Pain. JAMA Netw Open 2020; 3:e2028312. [PMID: 33315111 PMCID: PMC7737090 DOI: 10.1001/jamanetworkopen.2020.28312] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
IMPORTANCE Both noninvasive anatomic and functional testing strategies are now routinely used as initial workup in patients with low-risk stable chest pain (SCP). OBJECTIVE To determine whether anatomic approaches (ie, coronary computed tomography angiography [CTA] and coronary CTA supplemented with noninvasive fractional flow reserve [FFRCT], performed in patients with 30% to 69% stenosis) are cost-effective compared with functional testing for the assessment of low-risk SCP. DESIGN, SETTING, AND PARTICIPANTS This cost-effectiveness analysis used an individual-based Markov microsimulation model for low-risk SCP. The model was developed using patient data from the Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) trial. The model was validated by comparing model outcomes with outcomes observed in the PROMISE trial for anatomic (coronary CTA) and functional (stress testing) strategies, including diagnostic test results, referral to invasive coronary angiography (ICA), coronary revascularization, incident major adverse cardiovascular event (MACE), and costs during 60 days and 2 years. The validated model was used to determine whether anatomic approaches are cost-effective over a lifetime compared with functional testing. EXPOSURE Choice of index test for evaluation of low-risk SCP. MAIN OUTCOMES AND MEASURES Downstream ICA and coronary revascularization, MACE (death, nonfatal myocardial infarction), cost, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER) of competing strategies. RESULTS The model cohort included 10 003 individual patients (median [interquartile range] age, 60.0 [54.4-65.9] years; 5270 [52.7%] women; 7693 [77.4%] White individuals), who entered the model 100 times. The Markov model accurately estimated the test assignment, results of anatomic and functional index testing, referral to ICA, revascularization, MACE, and costs at 60 days and 2 years compared with observed data in PROMISE (eg, coronary CTA: ICA, 12.2% [95% CI, 10.9%-13.5%] vs 12.3% [95% CI, 12.2%-12.4%]; revascularization, 6.2% [95% CI, 5.5%-6.9%] vs 6.4% [95% CI, 6.3%-6.5%]; functional strategy: ICA, 8.1% [95% CI, 7.4%-8.9%] vs 8.2% [95% CI, 8.1%-8.3%]; revascularization, 3.2% [95% CI, 2.7%-3.7%] vs 3.3% [95% CI, 3.2%-3.4%]; 2-year MACE rates: coronary CTA, 2.1% [95% CI, 1.7%-2.5%] vs 2.3% [95% CI, 2.2%-2.4%]; functional strategy, 2.2% [95% CI, 1.8%-2.6%] vs 2.4% [95% CI, 2.3%-2.4%]). Anatomic approaches led to higher ICA and revascularization rates at 60 days, 2 years, and 5 years compared with functional testing but were more effective in patient selection for ICA (eg, 60-day revascularization-to-ICA ratio, CTA: 53.7% [95% CI, 53.3%-54.0%]; CTA with FFRCT: 59.5% [95% CI, 59.2%-59.8%]; functional testing: 40.7% [95% CI, 40.4%-50.0%]). Over a lifetime, anatomic approaches gained an additional 6 months in perfect health compared with functional testing (CTA, 25.16 [95% CI, 25.14-25.19] QALYs; CTA with FFRCT, 25.14 [95% CI, 25.12-25.17] QALYs; functional testing, 24.68 [95% CI, 24.66-24.70] QALYs). Anatomic strategies were less costly and more effective; thus, CTA with FFRCT dominated and CTA alone was cost-effective (ICERs ranged from $1912/QALY for women and $3,559/QALY for men) compared with functional testing. In probabilistic sensitivity analyses, anatomic approaches were cost-effective in more than 65% of scenarios, assuming a willingness-to-pay threshold of $100 000/QALY. CONCLUSIONS AND RELEVANCE The results of this study suggest that anatomic strategies may present a more favorable initial diagnostic option in the evaluation of low-risk SCP compared with functional testing.
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Affiliation(s)
- Júlia Karády
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Thomas Mayrhofer
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston
- School of Business Studies, Stralsund University of Applied Sciences, Stralsund, Germany
| | - Alexander Ivanov
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Borek Foldyna
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Michael T. Lu
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Maros Ferencik
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland
| | - Amit Pursnani
- Cardiology Division, Evanston Hospital, Evanston, Illinois
| | - Michael Salerno
- Departments of Medicine and Radiology, University of Virginia Health System, Charlottesville
| | - James E. Udelson
- Division of Cardiology, Tufts Medical Center, Boston, Massachusetts
| | - Daniel B. Mark
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Pamela S. Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Udo Hoffmann
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston
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24
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Kohli-Lynch CN, Thanassoulis G, Moran AE, Sniderman AD. The clinical utility of apoB versus LDL-C/non-HDL-C. Clin Chim Acta 2020; 508:103-108. [DOI: 10.1016/j.cca.2020.05.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 04/30/2020] [Accepted: 05/01/2020] [Indexed: 12/25/2022]
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25
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Kostis JB, Shetty M, Chowdhury YS, Kostis WJ. The Legacy Effect in Treating Hypercholesterolemia. J Cardiovasc Pharmacol Ther 2020; 25:291-298. [DOI: 10.1177/1074248420907256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background: The duration of randomized controlled clinical trials usually is approximately 3 to 5 years although hypercholesterolemia and other risk factors for atherosclerotic cardiovascular disease (ASCVD) are lifelong conditions. Objectives: The legacy effect, defined as the persistence of benefit of pharmacologic interventions in clinical trials after the end of the randomized phase when all participants receive active therapy, is used to examine the long-term benefit. We summarize the evidence for the existence of the legacy effect as it pertains to hypercholesterolemia, describe underlying mechanisms, and discuss its relevance to clinical practice. Methods: We examined all published (n = 13) randomized clinical trials of lipid-lowering agents compared to placebo or usual care with follow-up after the randomized phase for the presence or absence of a legacy effect. Results: A legacy effect was demonstrated in all studies. The current US and European guidelines recommend treatment with high-intensity statins for patients with manifest ASCVD and that individualized approach be used for primary prevention. Conclusion: The legacy effect results in significant long-term clinical benefits by preventing fatal and nonfatal events. This implies that early therapy would result in lower event rates. Long-term follow-up should be a part of clinical trial design in order to evaluate the presence or absence of a legacy effect.
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Affiliation(s)
- John B. Kostis
- Rutgers Robert Wood Johnson Medical School, Cardiovascular Institute, New Brunswick, NJ, USA
| | - Mrinali Shetty
- Rutgers Robert Wood Johnson Medical School, Cardiovascular Institute, New Brunswick, NJ, USA
| | - Yuvraj Singh Chowdhury
- Rutgers Robert Wood Johnson Medical School, Cardiovascular Institute, New Brunswick, NJ, USA
| | - William J. Kostis
- Rutgers Robert Wood Johnson Medical School, Cardiovascular Institute, New Brunswick, NJ, USA
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26
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Robinson JG. The next treatment paradigm in cardiovascular prevention? Lancet 2019; 394:2129-2131. [PMID: 31810608 DOI: 10.1016/s0140-6736(19)32949-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 11/08/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Jennifer G Robinson
- Departments of Epidemiology and Internal Medicine, Division of Cardiology, University of Iowa, Iowa City, IA 52242, USA.
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