Lipid-Lowering Strategies for Primary Prevention of Coronary Heart Disease in the UK: A Cost-Effectiveness Analysis

AimWe aimed to assess the cost effectiveness of four different lipid-lowering strategies for primary prevention of coronary heart disease initiated at ages 30, 40, 50, and 60 years from the UK National Health Service perspective.MethodsWe developed a microsimulation model comparing the initiation of a lipid-lowering strategy to current standard of care (control). We included 458,692 participants of the UK Biobank study. The four lipid-lowering strategies were: (1) low/moderate-intensity statins; (2) high-intensity statins; (3) low/moderate-intensity statins and ezetimibe; and (4) inclisiran. The main outcome was the incremental cost-effectiveness ratio for each lipid-lowering strategy compared to the control, with 3.5% annual discounting using 2021 GBP (& POUND;); incremental cost-effectiveness ratios were compared to the UK willingness-to-pay threshold of & POUND;20,000-& POUND;30,000 per quality-adjusted life-year.ResultsThe most effective intervention, low/moderate-intensity statins and ezetimibe, was projected to lead to a gain in quality-adjusted life-years of 0.067 per person initiated at 30 and 0.026 at age 60 years. Initiating therapy at 40 years of age was the most cost effective for all lipid-lowering strategies, with incremental cost-effectiveness ratios of & POUND;2553 (95% uncertainty interval: 1270, 3969), & POUND;4511 (3138, 6401), & POUND;11,107 (8655, 14,508), and & POUND;1,406,296 (1,121,775, 1,796,281) per quality-adjusted life-year gained for strategies 1-4, respectively. Incremental cost-effectiveness ratios were lower for male individuals (vs female individuals) and for people with higher (vs lower) low-density lipoprotein-cholesterol. For example, low/moderate-intensity statin use initiated from age 40 years had an incremental cost-effectiveness ratio of & POUND;5891 (3822, 9348), & POUND;2174 (772, 4216), and was dominant (i.e. cost saving; -2,760, 350) in female individuals with a low-density lipoprotein-cholesterol of & GE; 3.0, & GE; 4.0 and & GE; 5.0 mmol/L, respectively. Inclisiran was not cost effective in any sub-group at its current price.ConclusionsLow-density lipoprotein-cholesterol lowering from early ages is a more cost-effective strategy than late intervention and cost effectiveness increased with the increasing lifetime risk of coronary heart disease.

Automated summary

This study aimed to assess the cost effectiveness of four different lipid-lowering strategies for primary prevention of coronary heart disease initiated at different ages. The results showed that starting treatment at the age of 40 was the most cost-effective option for all lipid-lowering strategies, and early reduction of low-density lipoprotein cholesterol was more cost-effective than late intervention.