Using an apolipoprotein B target to guide lipid-lowering therapy intensification produced 1,324 additional quality-adjusted life-years compared with a non–high-density lipoprotein cholesterol strategy and was cost-effective, with an incremental cost-effectiveness ratio of $30,300 per quality-adjusted life-year gained in a computer simulation study of US primary prevention.
In a study published in JAMA, researchers evaluated 250,000 statin-eligible, atherosclerotic cardiovascular disease (ASCVD)–free US adults derived from National Health and Nutrition Examination Survey data collected from 2005 to 2016. Participants initiated statin therapy based on 2018 American Heart Association and American College of Cardiology guidelines, with treatment intensification guided by one of three targets: low-density lipoprotein cholesterol (LDL-C) less than 100 mg/dL, non–high-density lipoprotein cholesterol (non–HDL-C) less than 118 mg/dL, or apolipoprotein B (apoB) less than 78.7 mg/dL.
Over a lifetime horizon, intensification using a non–HDL-C target vs LDL-C prevented 617 ASCVD events per 250,000 patients, generated 965 additional quality-adjusted life-years, and reduced costs by approximately $2.1 million.
Compared with non–HDL-C, apoB-guided intensification was estimated to prevent 1,018 events and yielded 1,324 additional quality-adjusted life-years, with an incremental cost of $40.2 million, corresponding to an incremental cost-effectiveness ratio of $30,300 per quality-adjusted life-year gained. Among the strategies evaluated, apoB-guided care produced the greatest gains in quality-adjusted life-years.
At a willingness-to-pay threshold of $120,000 per quality-adjusted life-year, apoB was the preferred strategy in 65% of probabilistic simulations, compared with 25% for non–HDL-C and 10% for LDL-C.
Treatment intensification occurred in 64% of patients with an apoB target, compared with 57% with a non–HDL-C target and 51% with an LDL-C target. Total ASCVD events were 128,176 with apoB, 129,194 with non–HDL-C, and 129,811 with LDL-C. Treatment effects in the model were based on lipid reductions reported for moderate- and high-intensity statins and ezetimibe. Cardiovascular risk reductions were parameterized to changes in apoB. Costs included lipid-lowering therapy, screening, and ASCVD and non-ASCVD health care, with future costs discounted 3% annually.
Higher overall costs observed with the apoB strategy were largely driven by longer life expectancy and extended years of preventive treatment rather than the cost of apoB testing itself, which was minimal in the model.
In sex-specific analyses, apoB-guided intensification was associated with incremental cost-effectiveness ratios of $35,900 per quality-adjusted life-year in women and $26,600 per quality-adjusted life-year in men compared with a non–HDL-C strategy. In sensitivity analyses, apoB-based approaches yielded the highest quality-adjusted life-years in nearly all modeled scenarios, including analyses that applied treatment thresholds to a comparable number of patients. These findings suggest apoB may better guide treatment intensification in primary prevention settings.
Researchers noted that findings depended on model assumptions related to treatment effects and costs and reflected a health sector perspective that did not incorporate broader societal outcomes.
“Of the [lipid-lowering therapy] goals evaluated, an apoB goal was estimated to produce the largest reduction in ASCVD events and the largest gain in population health,” wrote lead study author Samuel Luebbe, MD, of Northwestern University Feinberg School of Medicine in Illinois, and colleagues.
Disclosures included grant support from the National Heart, Lung, and Blood Institute for Andrew E. Moran, MD, during the study; consulting fees from 3M for John T. Wilkins, MD, outside the submitted work; and consulting fees from Boehringer Ingelheim for Ciaran N. Kohli-Lynch, PhD, outside the submitted work. No other disclosures were reported. The study was supported by an American Heart Association Career Development Award to Kohli-Lynch.
Source: JAMA
