Using a coronary artery calcium (CAC) assessment score to guide the use of statins for the primary prevention of atherosclerotic cardiovascular disease in African Americans is cost effective, according to researchers.
Specifically, they found that restricting statin use to those individuals with CAC scores greater than 0, as suggested in the 2018 American College of Cardiology/American Heart Association (ACC/AHA) guidelines, would be cost effective compared with initiating statin therapy in all African Americans at intermediate risk for atherosclerotic cardiovascular disease (ASCVD).
Furthermore, Aferdita Spahillari, MD, MPH, Harvard Medical School, Massachusetts General Hospital, and colleagues, determined that using the CAC score-guided approach would allow 4 of every 10 screened individuals to avoid statin therapy.
The study was published in JAMA Cardiology.
According to Spahillari and colleagues, while African Americans have a greater risk of ASCVD compared with white individuals, they are less likely to receive guideline-recommended statin therapy. In addition, it is possible that concerns about the statin safety and effectiveness, as well as the possibility of overtreatment, leads to a lack of adherence to statin therapy.
In 2018 the ACC/AHA issued guidelines suggesting the use of a non-0 CAC score to guide statin therapy for primary ASCVD prevention in adults with an intermediate risk for ASCVD. This was in contrast to ACC/AHA 2013 guidelines, which do not make a strong recommendation for CAC assessment.
Here, Spahillari and colleagues wanted to evaluate the clinical and economic consequences of supplementing treatment guidelines with CAC assessment by comparing the 2018 guidelines with the 2013 guidelines. They constructed a microsimulation model to estimate life expectancy, quality of life, costs, and health outcomes based on data from the 472 intermediate risk participants in the Jackson Heart Study, as well as cost data, clinical event rates, probabilities, and quality of life weights from peer-reviewed literature.
Since the participants of this study were at intermediate risk for ASCVD, 100% had indications for statin therapy with the 2013 guidelines. Of 304 participants who underwent CAC assessment, 178 (58.6l%) had a non-0 CAC score, suggesting that using the CAC score–guided approach would allow 4 of every 10 screened individuals to go without statin therapy.
The authors found that fewer ASCVD events (26.86% versus 27.54%) but more statin-associated adverse events (3.14% versus 1.84%) occurred during use of the 2013 ACC/AHA guidelines compared with the 2018 ACC/AHA guidelines
In their base case simulation, Spahillari and colleagues determined that implementation of 2013 ACC/AHA guidelines without CAC assessment provided a marginally greater quality-adjusted life expectancy (0.0027 QALY), but at a higher cost ($428.97), and with an incremental cost-effectiveness ratio of $158,325/QALY, compared with the 2018 ACC/AHA guideline strategy. This, the authors pointed out, represents low-value care according to the ACC/AHA definition.
The authors also found that the 2018 ACC/AHA guideline strategy provided greater quality-adjusted life expectancy at a lower cost compared with the 2013 ACC/AHA guidelines (when there was a strong patient preference to avoid use of daily medication therapy). According to probability sensitivity analyses, the 2018 ACC/AHA guideline strategy with CAC assessment was cost-effective compared with the 2013 ACC/AHA guidelines without CAC assessment in 76% of simulations.
“[C]ontemporary 2018 ACC/AHA primary prevention guidelines including CAC assessment provided an apparently greater quality-adjusted life expectancy at a lower cost than a strategy without recommended CAC assessment when there was a strong patient preference to avoid use of daily medication therapy,” the authors concluded. “A shared decision-making conversation regarding primary ASCVD prevention should gauge patients’ preferences before consideration of CAC assessment for intermediate-risk individuals who prefer not to receive daily medication therapy.”
In a commentary accompanying the study, Eméfah Loccoh, BS, and Dhruv S. Kazi, MD, MSc, MS, both of the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Boston, Massachusetts, wrote that it is likely most patients won’t care about a 0.0027 QALY difference, which they pointed out is equivalent to less than a day of perfect health during an individual’s lifetime.
“But patients are likely to care about the fact that, with CAC imaging, there is a 4 in 10 chance of being able to forgo the need for daily statin therapy,” they added. “Our approach to the use of statins for primary prevention among intermediate risk African American patients should therefore be updated to reflect this new information.”
Using a coronary artery calcium (CAC) assessment score, per 2018 ACC/AHA guidelines, to guide the use of statins for the primary prevention of atherosclerotic cardiovascular disease in African Americans is cost effective.
Using the CAC score–guided approach would allow a significant number of screened individuals to avoid statin therapy.
Michael Bassett, Contributing Writer, BreakingMED™
Spahillari has no disclosures.
Loccoh and Kazi have no disclosures.
Cat ID: 4
Topic ID: 74,4,585,730,4,192,925