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.