Use of statins for the prevention of cardiovascular events

1. Use of statins for the prevention of cardiovascular events Citizen’s Council – November 2008

2. Cardiovascular disease in Britain 300,000 heart attacks annually 100,000 deaths Stroke: third most common cause of death Significant burden of disability 2 groups People at increased risk of developing CHD People with established CHD

3. Coronary Arteries

4. The Background Atorvastatin Fluvastatin Pravastatin Rosuvastatin Simvastatin (OTC) Statins represent the largest drug cost to the NHS (£500 million in 2007) Statin use is increasing by 30% a year in England Costs Simvastatin 40mg £3.40 per month atorvastatin 10-20mg (18.03-£24.64 per month)

5. The Main Issues • CVD risk is determined by principally • Age • Family history • Blood pressure • Cholesterol level • Smoking • The interaction between these risk factors is complex but only 3,4 and 5 are amenable to intervention • Previous history of CVD adds substantially to the risk of another event and so may provide the basis for an important clinical sub group • Lowering cholesterol alone reduces risk in all groups • Is it cost effective for the NHS to treat everyone with statins or just some individuals

6. Consider the Evidence • Lowering cholesterol alone reduces risk of future CVD events, but the other factors also matter (BP, smoking) • Primary prevention • The benefit of a statin for those who have not had a CVD event varies widely depending on both level of cholesterol and the presence of the other factors contributing to their baseline risk in particular age and perhaps gender • Secondary prevention • In those with a history of previous CVD (e.g. angina, heart attack, stroke) benefit of statin use in reducing future risk is substantial for all individuals • Cost effectiveness also varies depending on • the overall baseline risk of future CVD events • the price of the drug recommended, • For secondary prevention the ICERs are much lower than for primary prevention

7. Results: Secondary CVD prevention Source: AR, Table 81

8. Primary preventioncost per QALY of commencing statin therapy in males and females at an annual risk of a CHD event between 3% and 0.5%

9. Results of incremental analysis of treatment strategies (Males)

10. Issues to consider • Should all people be offered statins paid for by the NHS within the current cost effectiveness criteria used by NICE or should we use different ICER thresholds to differentiate between subgroups e.g. • Age/gender • Cholesterol level at initiation of treatment • Primary versus secondary prevention • Should provision of NHS treatment be contingent on alteration of life style (e.g. diet and smoking) • Should the ‘budget impact’ of a decision effecting millions of people and possibly costing the NHS many millions of pounds be taken into account • Should ‘over the counter’ statins (paid for by the individual) be recommended for low risk groups who are likely to be the least cost effective to treat on the NHS

11. Report Back Working in groups • Try to come up with some general recommendations to answer the questions • What problems did you face?

13. Thank you and Questions?