Assessing the Cost Effectiveness of an Incremental Lipid-Lowering Therapy Approach After Coronary Artery Bypass Grafting Using Nationwide Data.
| Title: | Assessing the Cost Effectiveness of an Incremental Lipid-Lowering Therapy Approach After Coronary Artery Bypass Grafting Using Nationwide Data. |
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| Authors: | Deo SV; Louis Stokes Cleveland VA Medical Center Cleveland Ohio USA.; Case Western School of Medicine Cleveland Ohio USA.; School of Health and Wellbeing University of Glasgow UK.; Ciminata G; School of Health Technology and Assessment University of Glasgow UK.; Mahalwar G; Department of Medicine Cleveland Clinic Cleveland Ohio USA.; Salerno PRVO; Case Western School of Medicine Cleveland Ohio USA.; Harrington Heart and Vascular Institute Cleveland Ohio USA.; McAllister DA; School of Health Technology and Assessment University of Glasgow UK.; Elgudin YE; Louis Stokes Cleveland VA Medical Center Cleveland Ohio USA.; Case Western School of Medicine Cleveland Ohio USA.; Orkaby A; New England GRECC (Geriatric Research, Education, and Clinical Center) VA Boston Medical Center Boston Massachusetts USA.; Division of Aging, Department of Medicine, Brigham & Women's Hospital Harvard Medical School Boston Massachusetts USA.; Virani S; Department of Cardiovascular Medicine The Aga Khan University Karachi Pakistan.; Baylor School of Medicine Houston Texas USA.; Fremes S; Division of Cardiac Surgery, Sunnybrook Health Sciences Center University of Toronto Toronto Ontario Canada.; Rajagopalan S; Case Western School of Medicine Cleveland Ohio USA.; Harrington Heart and Vascular Institute Cleveland Ohio USA.; Sattar N; School of Cardiovascular and Metabolic Health University of Glasgow Glasgow UK.; Pell JP; School of Health and Wellbeing University of Glasgow UK. |
| Source: | Journal of the American Heart Association [J Am Heart Assoc] 2026 Apr 21; Vol. 15 (8), pp. e040272. Date of Electronic Publication: 2026 Apr 07. |
| Publication Type: | Journal Article |
| Language: | English |
| Journal Info: | Publisher: Wiley-Blackwell Country of Publication: England NLM ID: 101580524 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 2047-9980 (Electronic) Linking ISSN: 20479980 NLM ISO Abbreviation: J Am Heart Assoc Subsets: MEDLINE |
| Imprint Name(s): | Original Publication: Oxford : Wiley-Blackwell |
| MeSH Terms: | Coronary Artery Bypass*/adverse effects ; Coronary Artery Bypass*/economics ; Hydroxymethylglutaryl-CoA Reductase Inhibitors*/therapeutic use ; Hydroxymethylglutaryl-CoA Reductase Inhibitors*/economics ; Coronary Artery Disease*/surgery ; Coronary Artery Disease*/economics ; Anticholesteremic Agents*/therapeutic use ; Anticholesteremic Agents*/economics ; Dyslipidemias*/drug therapy ; Dyslipidemias*/economics ; Dyslipidemias*/blood ; Dyslipidemias*/diagnosis ; Drug Costs*; United States/epidemiology ; Ezetimibe/therapeutic use ; Ezetimibe/economics ; Cholesterol, LDL/blood ; Humans ; Cost-Benefit Analysis ; Male ; Female ; Quality-Adjusted Life Years ; Aged ; PCSK9 Inhibitors ; Markov Chains ; Middle Aged ; Models, Economic ; Treatment Outcome ; Monte Carlo Method ; Cost-Effectiveness Analysis ; Proprotein Convertase 9 |
| Abstract: | 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. |
| Contributed Indexing: | Keywords: Markov model; PCSK9 inhibitor; bempedoic acid; cost effectiveness; ezetimibe; lipid‐lowering therapy; statins |
| Substance Nomenclature: | 0 (Hydroxymethylglutaryl-CoA Reductase Inhibitors); EOR26LQQ24 (Ezetimibe); 0 (PCSK9 Inhibitors); 0 (Cholesterol, LDL); EC 3.4.21.- (PCSK9 protein, human); 0 (Anticholesteremic Agents); EC 3.4.21.- (Proprotein Convertase 9) |
| Entry Date(s): | Date Created: 20260407 Date Completed: 20260424 Latest Revision: 20260424 |
| Update Code: | 20260424 |
| DOI: | 10.1161/JAHA.124.040272 |
| PMID: | 41944180 |
| Database: | MEDLINE |
Journal Article