Treating Young Adults With High LDL May Be Cost-Effective

Treating elevated low-density lipoprotein cholesterol (LDL-C) in adults younger than 40 with statins is highly cost-effective in men, and intermediately cost-effective in women, a new report suggests.

In a simulated model based on data from the US National Health and Nutrition Examination Survey (NHANES), lipid lowering with statins or lifestyle interventions in this age group would prevent or reduce the risk of atherosclerotic cardiovascular disease (ASCVD) and improve quality of life in later years.

The findings were published online today in the Journal of the American College of Cardiology.

Dr Andrew Moran

“My group does epidemiologic analyses with cohort studies as well as health economic analyses like this one, and if you have long-term longitudinal observation, you see that the early exposures are important for what happens later,” senior author Andrew E. Moran, MD, Columbia University Irving Medical Center, New York City, told | Medscape Cardiology.

“But when it comes to treatment studies that a lot of the treatment guidelines are based on, those are usually short-term, and they usually enroll older people. We saw the gap in the evidence that this paper tries to fill,” Moran said.

His group used a computer simulation model to synthesize evidence from observational cohort studies and clinical trials of statin treatment, as well as health services data on the costs of medicines and treatments.

Combining information from these sources, the investigators made their best estimates of the potential health benefits and costs of treating high cholesterol earlier in life, compared with standard care, which was statin treatment at age 40, or if LDL-C was 190 mg/dL or greater.

Lipid lowering incremental to standard care with moderate-intensity statins or intensive lifestyle interventions was simulated starting when young adult LDL-C was either ≥160 mg/dL or ≥130 mg/dL.

They found that approximately 27% of young adults who are free of ASCVD have LDL-C ≥130 mg/dL, and 9% have LDL-C of ≥160 mg/dL.

Their model projected that treating adults younger than 40 with statins or lifestyle interventions would prevent lifetime ASCVD events and increase quality-adjusted life years (QALYs) compared with standard care, which would begin treatment at age 40.

Incremental cost-effectiveness ratios (ICERs) were $31,000/QALY for statin treatment in young adult men with LDL-C ≥130 mg/dL, and $106,000/QALY for statin treatment in young women with LDL-C ≥130 mg/dL.

Intensive lifestyle intervention was more costly and less effective than statin therapy.

“We are straining to find these young adults with very high cholesterol,” Moran noted. “A lot of young adults don’t even see a doctor. This is an argument for engaging them in their healthcare and getting them involved in some basic screening. Atherosclerosis is a long-term process that starts in childhood for a lot of people.”

More innovative approaches may be needed, because the traditional healthcare system is not doing a good job of reaching young adults, he added. “Many of them may not have adequate health insurance. They need healthcare in nontraditional ways; convenience is really important for them. Perhaps part of the solution here is to think about ways of reaching this particular group that is not engaged with healthcare generally.”

Time to Relax the Age 40 Threshold

The US Preventive Services Task Force and the American College of Cardiology/American Heart Association should emphasize lifetime risk of elevated cholesterol, Paul A. Heidenreich, MD, MS, Stanford University School of Medicine, Stanford, California, and colleagues write in an accompanying editorial.

Dr Paul Heidenreich

“In addition to calculating 10-year risk, we should calculate years of life lost (or QALYs lost) from unhealthy LDL-C levels, and both lifestyle and pharmacologic treatment should be considered to treat high LDL-C in adults regardless of age. We also need to communicate that the mantra ‘lower is better’ applies not only to a single measurement but to lifetime exposure to LDL-C,” the editorialists write.

“I think treatment should be earlier than age 40,” Heidenreich told | Medscape Cardiology.

“Part of the reason that 40 was chosen as a threshold was because everyone looked at 10-year, or even 20-year risk, and thought there was no reason to worry until you get older. It’s interesting that we never accepted that with high blood pressure. But more and more, we are learning that it is a lifelong process,” he said.

“Statins are getting less and less expensive, and their safety is more and more established with every decade that goes by. I definitely agree with this paper that it would actually make sense to be starting much earlier for those with elevated CVD risk from their high cholesterol.”

The study was supported by the U.S. National Heart, Lung, and Blood Institute (NHLBI), the Medical Research Council, Swindon, UK. Moran and Heidenreich have disclosed no relevant financial relationships.

J Am Coll Cardiol. Published online November 8, 2021. Abstract, Editorial

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