Related Experiment Video
Updated: Apr 8, 2026
Author Spotlight: Enhancing Coronary Artery Revascularization
Published on: September 15, 2023
Assessing the Cost Effectiveness of an Incremental Lipid-Lowering Therapy Approach After Coronary Artery Bypass
Salil V Deo1,2,3, Giorgio Ciminata4, Gauranga Mahalwar5
1Louis Stokes Cleveland VA Medical Center Cleveland Ohio USA.
Insights
A stepwise lipid-lowering therapy approach using statins and ezetimibe effectively reduces the need for expensive PCSK9 inhibitors in US veterans post-coronary artery bypass grafting. This strategy proved cost-effective, offering significant health gains at low willingness-to-pay thresholds.
Area of Science:
- Cardiovascular Medicine
- Health Economics
- Pharmacoeconomics
Background:
- Lipid-lowering therapy (LLT) is crucial for patients post-coronary artery bypass grafting (CABG).
- The high cost of novel agents like PCSK9 inhibitors (PCSK9is) limits their widespread use.
- Mathematical modeling is essential to evaluate cost-effective LLT strategies.
Purpose of the Study:
- To model a stepwise LLT approach for US veterans post-CABG.
- To assess the necessity of expensive drugs like PCSK9is within this strategy.
- To determine the cost-effectiveness of this stepwise LLT model compared to observed practice.
Main Methods:
- Monte Carlo simulations for stepwise initiation of high-intensity statins, ezetetimibe, and PCSK9is.
- Lifetime Markov model incorporating stroke, myocardial infarction, revascularization, and mortality rates.
- Analysis of treatment costs and quality-adjusted life years (QALYs) from a healthcare perspective.
Main Results:
- The study analyzed 27,443 US veterans post-CABG, with a median LDL-C of 129 mg/dL.
- Stepwise LLT achieved target levels in 42% with statins alone and 37% with added ezetetimibe.
- Only 6% required bempedoic acid or PCSK9is, projecting 0.8 life years gained over 30 years.
- The median incremental cost-effectiveness ratio was $15,232/QALY, with 100% cost-effectiveness at >$20,000 willingness-to-pay.
Conclusions:
- A stepwise LLT approach with high-intensity statins and ezetetimibe minimizes the need for PCSK9 inhibitors.
- This strategy is highly cost-effective, even at low willingness-to-pay thresholds.
- The findings support optimized LLT sequencing for improved patient outcomes and resource allocation.
Background:
Lipid-lowering therapy (LLT) is important for risk reduction for patients after coronary artery bypass grafting. Cost limits the wider use of PCSK9 (proprotein convertase subtilsin/kexin type 9) inhibitors (PCSK9is) and newer drugs. Hence, mathematical modeling was performed on a nationwide cohort of US veterans post coronary artery bypass grafting to understand the need for expensive drugs like PCSK9is and the cost effectiveness of this model was evaluated.
Methods:
First, Monte Carlo simulations were used to model the stepwise initiation of high-intensity statins, ezetimibe, and PCSK9i therapy for each patient to lower their low-density lipoprotein cholesterol levels to recommended targets. Next, a lifetime Markov model was constructed with stroke, myocardial infarction, repeat revascularization, and mortality rates obtained our study cohort of nationwide US veterans post coronary artery bypass grafting. LLT treatment costs and quality adjusted life years were used to determine the cost effectiveness of this stepwise LLT approach versus observed clinical practice from the health care perspective. Probabilistic models were fit and results for cost effectiveness reported using incremental cost-effectiveness ratio per quality adjusted life year gained over the lifetime.
Results:
For 27 443 US veterans post- coronary artery bypass grafting (mean age 66 years, 10% Black) with a median low-density lipoprotein cholesterol 129 (interquartile range, 95.2-180) mg/dL, the 42% and 37% reached target LLT by statin intensification only and including ezetimibe, respectively. Only 6% required bempedoic acid or PCSK9is after the preceding steps. Such stepwise LLT reduction projected 0.8 life years gained over the 30-year period. With a median incremental cost-effectiveness ratio of percent 15 232 (interquartile range, 13 520-17 769) per quality adjusted life year gained, this stepwise approach reached 100% probability for being cost effective (compared with observed clinical practice) at willingness-to-pay thresholds >$20 000.
Conclusions:
Few patients needed bempedoic acid or PCSK9is when simulating stepwise LLT with high-intensity statins and ezetimibe. Such an approach was observed as cost effective at very low willingness-to-pay thresholds.
Related Concept Videos
01:26Atherosclerosis III: Management
01:27Coronary Artery Disease V: Interprofessional Care
01:20Lipid-Lowering Drugs: Statins and Miscellaneous Agents
01:26Coronary Artery Disease IV: Preventive Measures
01:27Peripheral Artery Disease III: Interprofessional Care
01:26Angina IV: Management