Cost-Effectiveness of Coronary Artery Calcium Testing for Coronary Heart and Cardiovascular Disease Risk Prediction to Guide Statin Allocation: The Multi-Ethnic Study of Atherosclerosis (MESA)

Abstract

BackgroundThe Multi-Ethnic Study of Atherosclerosis (MESA) showed that the addition of coronary artery calcium (CAC) to traditional risk factors improves risk classification, particularly in intermediate risk asymptomatic patients with LDL cholesterol levels <160 mg/dL. However, the cost-effectiveness of incorporating CAC into treatment decision rules has yet to be clearly delineated.ObjectiveTo model the cost-effectiveness of CAC for cardiovascular risk stratification in asymptomatic, intermediate risk patients not taking a statin. Treatment based on CAC was compared to (1) treatment of all intermediate-risk patients, and (2) treatment on the basis of United States guidelines.MethodsWe developed a Markov model of first coronary heart disease (CHD) and cardiovascular disease (CVD) events. We modeled statin treatment in intermediate risk patients with CAC≥1 and CAC≥100, with different intensities of statins based on the CAC score. We compared these CAC-based treatment strategies to a “treat all” strategy and to treatment according to the Adult Treatment Panel III (ATP III) guidelines. Clinical and economic outcomes were modeled over both five- and ten-year time horizons. Outcomes consisted of CHD and CVD events and Quality-Adjusted Life Years (QALYs). Sensitivity analyses considered the effect of higher event rates, different CAC and statin costs, indirect costs, and re-scanning patients with incidentalomas.ResultsWe project that it is both cost-saving and more effective to scan intermediate-risk patients for CAC and to treat those with CAC≥1, compared to treatment based on established risk-assessment guidelines. Treating patients with CAC≥100 is also preferred to existing guidelines when we account for statin side effects and the disutility of statin use.ConclusionCompared to the alternatives we assessed, CAC testing is both effective and cost saving as a risk-stratification tool, particularly if there are adverse effects of long-term statin use. CAC may enable providers to better tailor preventive therapy to patients' risks of CVD.

2016 SCCT/STR guidelines for coronary artery calcium scoring of noncontrast noncardiac chest CT scans: A report of the Society of Cardiovascular Computed Tomography and Society of Thoracic Radiology

“…25 Two prominent studies have shown that using CAC testing is more cost effective than the current widespread statin use that is advocated by the ACC/AHA pooled cohort equations or "treat all" strategies. 26 It has outperformed risk factor based paradigms such as the Framingham Risk Score (FRS), 3 the European Society of Cardiology Score 4 and the 2013 AHA/ACC Pooled Cohort Equations, 5 and, in 3 prospective, population-based outcome trials demonstrated an extremely high net reclassification index (NRI) of the FRS, ranging from 52% to 66% in the intermediate risk group. 16,27,28 The inclusion of CAC in guidelines is summarized in Table 2.…”

Determinants of future cardiovascular health in women with a history of preeclampsia

“…[40][41][42] This may be helpful as surrogate endpoints for intervention studies, as well as potentially add to global CVD risk assessment and guide treatment decisions. [43][44][45][46][47] Subclinical atherosclerosis is commonly assessed by carotid intima-media thickness (cIMT), coronary artery calcium score (CACS), coronary computed tomography angiography (CCTA) and cardiac magnetic resonance imaging (CMR). [5,[46][47][48][49][50][51][52][53][54][55][56][57][58] In recent years, some groups have started to evaluate these imaging techniques in former preeclampsia patients, as discussed below.…”

Clinical efficacy of statins in the prevention and treatment of coronary heart disease

“…The total incidence of adverse reactions of patients with coronary heart disease in the observation group of patients with coronary heart disease was significantly reduced (3.08%) compared with that in the control group (18.46%) (P<0.05). These findings proved that in the treatment of patients with coronary heart disease, statins could regulate the blood lipid level and myocardial cell autorhythmicity, increase the vascular endothelial function, stabilize the coronary atherosclerotic plaque, and resist the inflammation of myocardial cell and oxidation [9,10]. As a result, the patients' condition and the life quality of patients with coronary heart disease were significantly improved.…”