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Ann Intern Med. 2010 Jan 19;152(2):69-77. doi: 10.7326/0003-4819-152-2-201001190-00004.

Optimizing statin treatment for primary prevention of coronary artery disease.

Author information

  • 1University of Michigan and Veteran Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA. rhayward@umich.edu

Erratum in

  • Ann Intern Med. 2011 Jun 21;154(12):848.

Abstract

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.

Comment in

PMID:
20083825
[PubMed - indexed for MEDLINE]
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