Systematic coronary artery calcium scoring (CAC) screening and treatment of individuals with a family history of premature coronary artery disease (FHCAD) and subclinical disease was found to be more cost-effective than management based on statin treatment thresholds, according to a study published in JACC: Cardiovascular Imaging.
Drivers of cost-effectiveness of a CAC-guided treatment strategy using real-world statin treatment and adherence outcomes were evaluated in patients with FHCAD who were at low- or intermediate-risk for CAD. The CAC strategy was compared with standard care involving statin treatment in patients considered to be at intermediate risk participants for the disease.
Researchers developed a microsimulation model using data from 1083 participants enrolled in the Coronary Artery Calcium Score: Use to Guide Management of HerediTary Coronary Artery Disease trial. Participants were stratified according to their coronary calcium score (CCS; CCS=0; n=587; median age, 54 years; 39% men; CCS >0; n=496; median age, 59 years; 59% men).
Cost-effectiveness, was based on real-world statin prescribing, was examined over a 15-year period, and took into account the effect and of subclinical disease on guideline-directed therapy adherence.
Statins were indicated for 45% of study participants according to the CAC strategy and for 27% using American College of Cardiology/American Heart Association (2019) treatment strategies. The CAC strategy was more costly (average increase over 15 years, $145; P <.01) and more effective (average, 0.0097 quality-adjusted life years [QALY]; P <.01), with an incremental cost-effective ratio (ICER) of $15,014 ($/QALY; P <.01), compared with application of a statin treatment threshold of 7.5%.
The CAC ICER was driven by statin prescription cost and CAC acquisition, and improved in the following patient subgroups: men, patients aged >60 years, and individuals with a 10-year risk pooled cohort equation risk ≥7.5%. CAC scanning of low-risk patients (ie, 10-year risk <5%) or those aged 40 to 50 years was not found to be cost-effective.
“Our study suggests the investment required (which may include third-party payer support) to facilitate access to CAC is both clinically justified and economically prudent,” noted the investigators.
Study limitations include the fact that probabilities were assumed to be constant and may underestimate the risk from years 10 to 15, and that the model assumed a common baseline use for all individuals, regardless of age and sex.
“The CAC-guided strategy was highly cost-effective with an ICER <$20,000/QALY with 90% of iterations meeting a willingness-to-pay threshold of $50,000,” the study authors concluded. “The CAC strategy dominated standard risk factor assessment and was cost-saving when baseline Pooled Cohort Equations risk was ≥7.5% and was highly cost-effective for those at borderline cardiovascular disease risk. Systematic scanning of those with baseline risk <5% or between 40 and 50 years of age was not cost-effective.”
Venkataraman P, Kawakami H, Huynh Q, et al. Cost-effectiveness of coronary artery calcium scoring in people with a family history of coronary disease [published online January 13, 2021]. JACC Cardiovasc Imaging. doi: 10.1016/j.jcmg.2020.11.008