Intensive versus standard dose statin therapy: the costs and benefits for patients with acute coronary syndrome

Introduction: Recent NICE guidance in England and Wales states that statin therapy for secondary CVD should "usually be initiated with a drug with a low acquisition cost (taking into account required daily dose and product price per dose)". Intensive dose statin therapy is more costly than standard dose, but offers additional benefits and may potentially be more cost effective for a sub-group of high risk patients. Objective: To determine if the strategy of treating ACS patients with intensive dose statin compared with standard dose statin can be considered to be cost effective and to what extent these results are influenced by the age of the patient at start of treatment. Methods: A Markov model was used to explore the costs and health outcomes associated with a lifetime of intensive dose (represented by 80mg atorvastatin) versus standard dose (represented by 20mg simvastatin) treatment for patients with acute coronary syndrome. Health states included unstable angina, MI, stroke, fatal CHD, fatal stroke, or non vascular death. The benefits associated with statin treatment were modelled by applying the relative risks from a meta-analysis of 4 large RCTs reporting clinical endpoints. Costs and utilities assigned to health states were derived from a review of published evidence. Results: Treatment with intensive dose statin therapy offers additional benefits over standard dose therapy. The cost offsets through avoided events are less than the associated treatment costs and result in a cost per QALY of around £24,000 for patients with ACS starting treatment at 60 years of age and falling to around £14,000 for patients starting treatment at 70 years. The key driver of cost effectiveness is the relative risk for mortality. Conclusions: This analysis suggests that intensive statin regimens (represented by atorvastatin 80mg/day) are cost effective compared with standard statin regimens (represented by simvastatin 20mg/day) for patients with ACS over the age of 60 years. A recent registry study reports a mean age of 70 years for ACS patients admitted to UK hospitals and hence this comparison applies to the great majority of ACS patients