This Article Free upon publication Full Text Full Text (PDF) CME: Take the course for this article: Circulation: May 8, 2007, Volume 115, Number 18 Data Supplement All Versions of this Article: 115/18/2398    most recent CIRCULATIONAHA.106.667683v1 Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Chan, P. S. Articles by Vijan, S. Search for Related Content PubMed PubMed Citation Articles by Chan, P. S. Articles by Vijan, S. Related Collections Health policy and outcome research Lipids Secondary prevention Acute coronary syndromes

(Circulation. 2007;115:2398-2409.)
© 2007 American Heart Association, Inc.

Health Services and Outcomes Research

Incremental Benefit and Cost-Effectiveness of High-Dose Statin Therapy in High-Risk Patients With Coronary Artery Disease

Paul S. Chan, MD, MSc; Brahmajee K. Nallamothu, MD, MPH; Hitinder S. Gurm, MD; Rodney A. Hayward, MD; Sandeep Vijan, MD, MSc

From the University of Michigan Department of Internal Medicine (P.S.C., B.K.N., H.S.G., R.A.H., S.V.), and Veterans Affairs Ann Arbor Health Services Research & Development Center of Excellence (P.S.C., B.K.N., R.A.H., S.V.), Ann Arbor, Mich.

Reprint requests to Paul Chan, MD, MSc, Veterans Affairs Ann Arbor Health Services Research & Development Center for Excellence, Cardiology (111-A), 2215 Fuller Rd, Ann Arbor, MI 48105. E-mail paulchan{at}umich.edu

Received October 2, 2006; accepted March 15, 2007.

Background— Recent clinical trials found that high-dose statin therapy, compared with conventional-dose statin therapy, reduces the risk of cardiovascular events in patients with acute coronary syndromes (ACS) and stable coronary artery disease (CAD). However, the actual benefit and cost-effectiveness of high-dose statin therapy are unknown.

Methods and Results— We designed a Markov model to compare daily high-dose with conventional-dose statin therapy for hypothetical 60-year-old cohorts with ACS and stable CAD over patient lifetime. Pooled estimates for major clinical end points (all-cause mortality, myocardial infarction, stroke, rehospitalization, and revascularization) from relevant clinical trials were incorporated. Incremental benefit was quantified as quality-adjusted life-years (QALYs). Threshold analyses determined at what price difference high-dose statins would yield incremental cost-effective ratios below $50 000, $100 000, and $150 000 per QALY gained. In ACS patients, a high-dose versus conventional-dose statin strategy resulted in a gain of 0.35 QALYs. In threshold analyses, a high-dose statin strategy consistently yielded incremental cost-effective ratios below $30 000 per QALY even under conservative model assumptions. In stable CAD patients, a high-dose statin strategy yielded a gain of only 0.10 QALYs and was sensitive to model assumptions about statin efficacy. The daily cost difference between a high- and conventional-dose statin would need to be <$1.70, $2.65, and $3.55 to yield incremental cost-effective ratios below $50 000, $100 000, and $150 000 per QALY.

Conclusions— High-dose statin therapy is potentially highly effective and cost-effective in patients with ACS. In patients with stable CAD, however, the cost-effectiveness of high-dose statin therapy is highly sensitive to model assumptions about statin efficacy and cost. Use of high-dose statins can be supported on health economic grounds in patients with ACS, but the case is less clear for patients with stable CAD.

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