Optimizing Statin Treatment for Primary Prevention of Coronary Artery Disease
Optimizing Statin Treatment for Primary Prevention of Coronary Artery Disease
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DOI：
10.7326/0003-4819-152-2-201001190-00004
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发表时间：
2010-01-19
影响因子：
39.2
通讯作者：
Vijan, Sandeep
中科院分区：
文献类型：
--
作者：
Hayward, Rodney A.;Krumholz, Harlan M.;Vijan, Sandeep
背景资料：虽然治疗血脂目标尽管他汀类药物（“靶向治疗”）被广泛推荐用于预防冠状动脉疾病（CAD），但有些人主张根据个人的估计净效益给予固定剂量的他汀类药物（“定制治疗”）。目的：研究他汀类药物治疗的定制治疗方法与靶向治疗方法的比较。设计：他汀类药物治疗达标和定制治疗方法的人群水平效应模拟模型。数据来源：1994年至2009年的他汀类药物试验和全国代表性CAD风险因素数据。目标人群：美国。S.年龄在30 - 75岁之间，无心肌梗死病史的患者。时间范围：5年治疗的终身效应。视角：社会和患者。干预：根据一个人的5年CAD风险定制治疗（辛伐他汀，40 mg，用于5%至15%的CAD风险，阿托伐他汀，40 mg，对于CAD风险>15%）与根据国家胆固醇教育计划[NCEP] III指南递增他汀类药物剂量的达标治疗方法（包括一种强化治疗方法，只要NCEP III标准规定强化治疗是可选的，就能提高治疗效果）。质量调整生命年（QALs）：基本案例分析结果：与标准NCEP III方法相比，强化NCEP III方法在5年内多治疗了1500万人，多挽救了57万QALs。与强化NCEP III方法一样，量身定制的策略治疗了相似数量的患者，但节省了500，000多个QDIV，并使用高剂量他汀类药物治疗了更少的患者。敏感性分析结果：未发现达标治疗方法优于量身定制治疗的情况。局限性：模型假设是基于现有的临床数据，其中包括少数75岁或以上的人。与基于低密度脂蛋白胆固醇的靶向方法相比，定制的治疗策略可以预防更多的CAD事件，同时使用高剂量他汀类药物治疗更少的患者。结果是稳健的，即使假设有利于治疗目标的方法。
Background: Although treating to lipid targets ("treat to target") is widely recommended for coronary artery disease (CAD) prevention, some have advocated administering fixed doses of statins based on a person's estimated net benefit ("tailored treatment").Objective: To examine how a tailored treatment approach to statin therapy compares with a treat-to-target approach.Design: Simulated model of population-level effects of treat-to-target and tailored treatment approaches to statin therapy.Data Sources: Statin trials from 1994 to 2009 and nationally representative CAD risk factor data.Target Population: U. S. persons aged 30 to 75 years with no history of myocardial infarction.Time Horizon: Lifetime effects of 5 years of treatment.Perspective: Societal and patient.Intervention: Tailored treatment based on a person's 5-year CAD risk (simvastatin, 40 mg, for 5% to 15% CAD risk and atorvastatin, 40 mg, for CAD risk >15%) versus treat-to-target approaches that escalate statin dose per National Cholesterol Education Program [NCEP] III guidelines (including an intensive approach that advances treatment whenever intensification is optional by NCEP III criteria).Outcome Measures: Quality-adjusted life-years (QALYs).Results of Base-Case Analysis: Compared with the standard NCEP III approach, the intensive NCEP III approach treated 15 million more persons and saved 570 000 more QALYs over 5 years. The tailored strategy treated a similar number of persons, as did the intensive NCEP III approach, but saved 500 000 more QALYs and treated fewer persons with high-dose statins.Results of Sensitivity Analysis: No circumstances were found in which a treat-to-target approach was preferable to tailored treatment.Limitation: Model assumptions were based on available clinical data, which included few persons 75 years or older.Conclusion: A tailored treatment strategy prevents more CAD events while treating fewer persons with high-dose statins than low-density lipoprotein cholesterol-based target approaches. Results were robust, even with assumptions favoring a treat-to-target approach.