Cardiovascular Genetic Risk Testing for Targeting Statin Therapy in the Primary Prevention of Atherosclerotic Cardiovascular Disease: A Cost-Effectiveness Analysis

Circ Cardiovasc Qual Outcomes. 2018 Apr;11(4):e004171. doi: 10.1161/CIRCOUTCOMES.117.004171.

Abstract

Background: It is unclear whether testing for novel risk factors, such as a cardiovascular genetic risk score (cGRS), improves clinical decision making or health outcomes when used for targeting statin initiation in the primary prevention of atherosclerotic cardiovascular disease (ASCVD). Our objective was to estimate the cost-effectiveness of cGRS testing to inform clinical decision making about statin initiation in individuals with low-to-intermediate (2.5%-7.5%) 10-year predicted risk of ASCVD.

Methods and results: We evaluated the cost-effectiveness of testing for a 27-single-nucleotide polymorphism cGRS comparing 4 test/treat strategies: treat all, treat none, test/treat if cGRS is high, and test/treat if cGRS is intermediate or high. We tested a set of clinical scenarios of men and women, aged 45 to 65 years, with 10-year ASCVD risks between 2.5% and 7.5%. Our primary outcome measure was cost per quality-adjusted life-year gained. Under base case assumptions for statin disutility and cost, the preferred strategy is to treat all patients with ASCVD risk >2.5% without cGRS testing. For certain clinical scenarios, such as a 57-year-old man with a 10-year ASCVD risk of 7.5%, cGRS testing can be cost-effective under a limited set of assumptions; for example, when statins cost $15 per month and statin disutility is 0.013 (ie, willing to trade 3 months of life in perfect health to avoid 20 years of statin therapy), the preferred strategy (using a willingness-to-pay threshold of $50 000 per quality-adjusted life-year gained) is to test and treat if cGRS is intermediate or high. Overall, the results were not sensitive to assumptions about statin efficacy and harms.

Conclusions: Testing for a 27-single-nucleotide polymorphism cGRS is generally not a cost-effective approach for targeting statin therapy in the primary prevention of ASCVD for low- to intermediate-risk patients.

Keywords: cardiovascular disease; clinical decision making; genetic testing; quality-adjusted life-year; risk factors.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Aged
  • Atherosclerosis / blood
  • Atherosclerosis / economics
  • Atherosclerosis / genetics*
  • Atherosclerosis / prevention & control*
  • Clinical Decision-Making
  • Cost-Benefit Analysis
  • Decision Support Techniques
  • Decision Trees
  • Drug Costs
  • Dyslipidemias / blood
  • Dyslipidemias / drug therapy*
  • Dyslipidemias / economics
  • Dyslipidemias / genetics*
  • Female
  • Gene Expression Profiling / economics
  • Gene Expression Profiling / methods*
  • Genetic Association Studies
  • Genetic Markers
  • Genetic Predisposition to Disease
  • Health Status
  • Humans
  • Hydroxymethylglutaryl-CoA Reductase Inhibitors / economics
  • Hydroxymethylglutaryl-CoA Reductase Inhibitors / therapeutic use*
  • Lipids / blood*
  • Male
  • Markov Chains
  • Middle Aged
  • Models, Economic
  • Phenotype
  • Polymorphism, Single Nucleotide*
  • Predictive Value of Tests
  • Primary Prevention / economics
  • Primary Prevention / methods*
  • Quality-Adjusted Life Years
  • Risk Assessment
  • Risk Factors
  • Time Factors
  • Treatment Outcome

Substances

  • Genetic Markers
  • Hydroxymethylglutaryl-CoA Reductase Inhibitors
  • Lipids