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Residual cardiovascular risk reduction guided by lifetime benefit estimation in patients with symptomatic
Steven H J Hageman1, Jannick A N Dorresteijn1, Michiel L Bots2
1Department of Vascular Medicine, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands.
Insights
Personalized lifetime benefit guidance for cardiovascular disease (CVD) therapies significantly increases life years free from CVD events compared to standard risk factor management. This approach proves effective and potentially cost-effective for patients with existing vascular disease.
Area of Science:
- Cardiovascular Medicine
- Health Economics
- Preventive Cardiology
Background:
- Symptomatic atherosclerotic disease carries significant residual risk despite conventional management.
- Optimizing treatment strategies is crucial for improving long-term outcomes and cost-effectiveness.
Purpose of the Study:
- To compare the cost-effectiveness of blood pressure lowering, lipid-lowering, and antithrombotic therapies guided by predicted lifetime benefit versus traditional risk factor levels.
- To evaluate the impact of a lifetime benefit-guided strategy on cardiovascular disease (CVD)-free life years and events avoided in patients with symptomatic atherosclerotic disease.
Main Methods:
- A microsimulation model was used to compare two strategies in the UCC-SMART cohort (n=7697, 1996-2018): lifetime benefit-guided (SMART-REACH model) and risk factor-based (LDL-c <1.8 mmol/L, SBP <140 mmHg, antithrombotic medication).
- Effectiveness was measured by CVD-free life years gained and events avoided.
- Cost-effectiveness was assessed using the incremental cost-effectiveness ratio (ICER).
Main Results:
- Lifetime benefit-guided treatment increased CVD-free life years by 24,243 and avoided 940 events over 10 years, compared to 18,564 years and 857 events for risk factor-based treatment.
- The ICER for lifetime benefit-guided treatment was €15,092/QALY gained, while risk factor-based treatment was €9,933/QALY gained.
- Direct comparison showed lifetime benefit-guided treatment yielded 1871 additional QALYs at a cost of €36,538/QALY gained.
Conclusions:
- Guidance by predicted lifetime benefit is a more effective strategy for reducing residual CVD risk than conventional risk factor management.
- This personalized approach leads to more cardiovascular disease-free life years and avoids more events.
- Lifetime benefit-guided treatment represents an effective and potentially cost-effective strategy for managing patients with manifest vascular disease.
Aims:
To determine the (cost)-effectiveness of blood pressure lowering, lipid-lowering, and antithrombotic therapy guided by predicted lifetime benefit compared to risk factor levels in patients with symptomatic atherosclerotic disease.
Methods And Results:
For all patients with symptomatic atherosclerotic disease in the UCC-SMART cohort (1996-2018; n = 7697) two treatment strategies were compared. The lifetime benefit-guided strategy was based on individual estimation of gain in cardiovascular disease (CVD)-free life with the SMART-REACH model. In the risk factor-based strategy, all patients were treated the following: low-density lipoprotein cholesterol (LDL-c) < 1.8 mmol/L, systolic blood pressure <140 mmHg, and antithrombotic medication. Outcomes were evaluated for the total cohort using a microsimulation model. Effectiveness was evaluated as total gain in CVD-free life and events avoided, cost-effectiveness as incremental cost-effectivity ratio (ICER). In comparison to baseline treatment, treatment according to lifetime benefit would lead to an increase of 24 243 CVD-free life years [95% confidence interval (CI) 19 980-29 909] and would avoid 940 (95% CI 742-1140) events in the next 10 years. For risk-factor based treatment, this would be an increase of 18 564 CVD-free life years (95% CI 14 225-20 456) and decrease of 857 (95% CI 661-1057) events. The ICER of lifetime benefit-based treatment with a treatment threshold of ≥1 year additional CVD-free life per therapy was €15 092/QALY gained and of risk factor-based treatment €9933/QALY gained. In a direct comparison, lifetime benefit-based treatment compared to risk factor-based treatment results in 1871 additional QALYs for the price of €36 538/QALY gained.
Conclusion:
Residual risk reduction guided by lifetime benefit estimation results in more CVD-free life years and more CVD events avoided compared to the conventional risk factor-based strategy. Lifetime benefit-based treatment is an effective and potentially cost-effective strategy for reducing residual CVD risk in patients with clinical manifest vascular disease.
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