title: Cost-effectiveness of pravastatin therapy for survivors of myocardial infarction with average cholesterol levels. Lifetime cost effectiveness of simvastatin in a range of risk groups and age groups derived from a randomised trial of 20 536 people The Beaver Dam Health Outcomes study Development and validation of improved algorithms for the assessment of global cardiovascular risk in women: the Reynolds Risk Score. Prospective Study of Sudden Cardiac Death Among Women in the United States A prospective study in primary care in patients without vascular disease comparing levels of coronary risk factors in those recommended for lipid-lowering drugs based on either absolute risk or absolute risk reduction. Aspirin, Statins, or Both Drugs for the Primary Prevention of Coronary Heart Disease Events in Men: A CostUtility Analysis Lack of association between cholesterol and coronary heart disease mortality and morbidity and all-cause mortality in persons older than 70 years. Out-of-hospital cardiac arrest in the 1990's: a population-based study in the Maastricht area on incidence, characteristics and survival. Diagnostic testing in acute myocardial infarction: does patient age influence utilization patterns? The Worcester Heart Attack Study. Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomised trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration The West of Scotland coronary prevention study: economic benefit analysis of primary prevention with pravastatin Unwitnessed out-of-hospital cardiac arrest: is resuscitation worthwhile? Positive predictive value of the diagnosis of acute myocardial infarction in an administrative database Prevention of coronary heart disease with pravastatin in men with hypercholesterolemia. West of Scotland Coronary Prevention Study Group. A long-term perspective on the protective effects of an early invasive strategy in unstable coronary artery disease: two-year follow-up of the FRISC-II invasive study.
abstract: BACKGROUND The objective of this study was to assess the cost-effectiveness of pravastatin therapy in survivors of myocardial infa rct ion with average cholesterol levels . METHODS We performed a cost-effectiveness analysis based on actual clinical , cost , and health-related quality -of-life data from the Cholesterol and Recurrent Events ( CARE ) trial . Survival and recurrent coronary heart disease events were modeled from trial data in Markov models , with the use of different assumptions regarding the long-term benefit of therapy . RESULTS Pravastatin therapy increased quality -adjusted life expectancy at an incremental cost of $ 16,000 to $ 32,000 per quality -adjusted life-year gained . In subgroup analyses , the cost-effectiveness of pravastatin therapy was more favorable for patients > 60 years of age and for patients with pretreatment low-density lipoprotein cholesterol levels > 125 mg/dL. Results were sensitive to the cost of pravastatin and to assumptions about long-term survival benefits from pravastatin therapy . CONCLUSIONS The cost-effectiveness of pravastatin therapy in survivors of myocardial infa rct ion with average cholesterol levels compares favorably with other interventions Objectives To evaluate the cost effectiveness of 40 mg simvastatin daily continued for life in people of different ages with differing risks of vascular disease . Design A model developed from a r and omised trial was used to estimate lifetime risks of vascular events and costs of treatment and hospital admissions in the United Kingdom . Setting 69 hospitals in the UK . Participants 20 536 men and women ( aged 40 - 80 ) with coronary disease , other occlusive arterial disease , or diabetes . Interventions 40 mg simvastatin daily versus placebo for an average of 5 years . Main outcome measures Cost effectiveness of 40 mg simvastatin daily expressed as additional cost per life year gained . Major vascular event defined as non-fatal myocardial infa rct ion or death from coronary disease , any stroke , or revascularisation procedure . Results were extrapolated to younger and older age groups at lower risk of vascular disease than were studied directly , as well as to lifetime treatment . Results At the April 2005 UK price of � 4.87 ( € 7 ; $ 9 ) per 28 day pack of generic 40 mg simvastatin , lifetime treatment was cost saving in most age groups and vascular disease risk groups studied directly . Gains in life expectancy and cost savings decreased with increasing age and with decreasing risk of vascular disease . People aged 40 - 49 with 5 year risks of major vascular events of 42 % and 12 % at start of treatment gained 2.49 and 1.67 life years , respectively . Treatment with statins  remained cost saving or cost less than � 2500 per life year gained in people as young as 35 years or as old as 85 with 5 year risks of a major vascular event as low as 5 % at the start of treatment . Conclusions Treatment with statins  is cost effective in a wider population than is routinely treated at present The Beaver Dam Health Outcomes Study ( BDHOS ) is an ongoing longitudinal cohort study of health status and health-related quality of life for a r and om sample of adults ( age range at interview was 45 to 89 years ; mean = 64.1 , SD = 10.8 ) in a community population . In a face-to-face interview lasting approximately an hour , each participant responds to several batteries of questions . Included are a history of chronic medical conditions , current medi cations , and past surgeries ; the SF-36 ( a general health-status question naire ) ; the Quality of Well-being index ; self-rated health status on a five-point scale from " excellent " to " poor " ; and evaluation of current health using the method of time tradeoffs . The authors present results from 1,356 interviews on these four principal measures , reporting mean scores by sex , by age , and for persons reporting being affected by various medical conditions . They believe data from the BDHOS will provide research ers and policy makers a reference col lection of vital statistics for health-related quality of life . Additionally , the data provide a way to compare results from studies that utilize different indices from among the four principal measures of the BDHOS . Key words : health status ; quality of life ( health-related ) ; population study ; cohort study . ( Med Decis Making 1993;13:89 - 102 CONTEXT Despite improved underst and ing of atherothrombosis , cardiovascular prediction algorithms for women have largely relied on traditional risk factors . OBJECTIVE To develop and vali date cardiovascular risk algorithms for women based on a large panel of traditional and novel risk factors . DESIGN , SETTING , AND PARTICIPANTS Thirty-five factors were assessed among 24 558 initially healthy US women 45 years or older who were followed up for a median of 10.2 years ( through March 2004 ) for incident cardiovascular events ( an adjudicated composite of myocardial infa rct ion , ischemic stroke , coronary revascularization , and cardiovascular death ) . We used data among a r and om two thirds ( derivation cohort , n = 16 400 ) to develop new risk algorithms that were then tested to compare observed and predicted outcomes in the remaining one third of women ( validation cohort , n = 8158 ) . MAIN OUTCOME MEASURE Minimization of the Bayes Information Criterion was used in the derivation cohort to develop the best-fitting parsimonious prediction models . In the validation cohort , we compared predicted vs actual 10-year cardiovascular event rates when the new algorithms were compared with models based on covariates included in the Adult Treatment Panel III risk score . RESULTS In the derivation cohort , a best-fitting model ( model A ) and a clinical ly simplified model ( model B , the Reynolds Risk Score ) had lower Bayes Information Criterion scores than models based on covariates used in Adult Treatment Panel III . In the validation cohort , all measures of fit , discrimination , and calibration were improved when either model A or B was used . For example , among participants without diabetes with estimated 10-year risks according to the Adult Treatment Panel III of 5 % to less than 10 % ( n = 603 ) or 10 % to less than 20 % ( n = 156 ) , model A reclassified 379 ( 50 % ) into higher- or lower-risk categories that in each instance more accurately matched actual event rates . Similar effects were achieved for clinical ly simplified model B limited to age , systolic blood pressure , hemoglobin A(1c ) if diabetic , smoking , total and high-density lipoprotein cholesterol , high-sensitivity C-reactive protein , and parental history of myocardial infa rct ion before age 60 years . Neither new algorithm provided substantive information about women at very low risk based on the published Adult Treatment Panel III score . CONCLUSION We developed , vali date d , and demonstrated highly improved accuracy of 2 clinical algorithms for global cardiovascular risk prediction that reclassified 40 % to 50 % of women at intermediate risk into higher- or lower-risk categories Background —There are few data regarding the determinants of sudden cardiac death ( SCD ) in women , primarily because of their markedly lower rate of SCD compared with men . Nonetheless , existing data , although sparse , suggest possible gender differences in risk factors for SCD . Methods and Results —In this prospect i ve cohort of 121 701 women aged 30 to 55 years at baseline , SCD was defined as death within 1 hour of symptom onset . From 1976 to 1998 , 244 SCDs were identified . Although the risk of SCD increased markedly with age , the percentage of cardiac deaths that were sudden decreased . Most ( 69 % ) women who suffered a SCD had no history of cardiac disease before their death . However , almost all of the women who died suddenly ( 94 % ) had reported at least 1 coronary heart disease risk factor . Smoking , hypertension , and diabetes conferred markedly elevated ( 2.5- to 4.0-fold ) risk of SCD , similar to that conferred by a history of nonfatal myocardial infa rct ion ( relative risk , 4.1 ; 95 % confidence interval , 2.9 to 6.7 ) . Family history of myocardial infa rct ion before age 60 years and obesity were associated with moderate ( 1.6-fold ) elevations in risk . With regard to mechanism , 88 % of SCDs were classified as arrhythmic . In 76 % of these , the first rhythm documented was ventricular tachycardia or ventricular fibrillation . Conclusions —These prospect i ve data suggest that , as in men , coronary heart disease risk factors predict risk of SCD in women and that SCD is usually an arrhythmic death . Therefore , prevention of atherosclerosis or ventricular arrhythmias may reduce the incidence of SCD in women In the United Kingdom , the current recommendation is that lipid-lowering drugs should be prescribed for primary prevention only to subjects with an absolute coronary risk ( AR ) greater than 15 % in 5 years ( i.e. , myocardial infa rct ion or angina ) . However , to achieve greater benefit it may be preferable to direct treatment to those patients showing the greatest absolute risk reduction ( ARR ) . The aim of this study was to compare the characteristics of subjects eligible for lipid-lowering drugs based on the AR criteria or on an ARR of > 4.45 % . A prospect i ve study was carried out over 29 months in primary care in a part of the United Kingdom with a prevalence of coronary disease nearly 20 % above the national average . Risk factors were recorded in men and women aged 30 - 75 years who were being considered by their primary care physician for lipid-lowering drug therapy .  Of the 2351 patients included in the study , 2139 ( 91 % ) and 101 ( 4.3 % ) were , respectively , below and above the criteria for treatment by both AR and ARR criteria . In 111 ( 4.7 % ) subjects , treatment was recommended based on only one of the criteria -82 on AR and 29 on ARR . Comparing these two groups , those treated on AR only were older ( mean age 68.1 years [ SD , 4.1 ] vs. 49.1 years [ SD , 4.6 ] ; p<0.0001 ) and had a lower total cholesterol ( 260 vs. 288 mg/dL ; p=0.015 ) ; higher high-density lipoprotein cholesterol ( 50 vs. 43 mg/dL ; p=0.003 ) , lower low-density lipoprotein cholesterol ( 160 vs. 184 mg/dL ; p=0.03 ) , a lower total to high-density lipoprotein cholesterol ratio ( 5.4 vs. 7.1 ; p<0.0001 ) , and lower triglycerides ( 258 vs. 435 mg/dL ; p=0.007 ) . The AR group also had a higher mean systolic blood pressure ( 170.9 vs. 158.9 mm Hg ; p=0.013 ) , presumably an attribute of their greater age . Although the AR and ARR groups did not show a difference in the proportion of males or diabetics , there was a significantly greater proportion of smokers in the latter group ( 72 % vs. 35 % ; p=0.001 ) . In conclusion , treatment recommendations based on AR alone would result in nontreatment of young subjects with significant hyperlipidemia and at high relative risk of coronary disease , whereas lipid-lowering drugs would be given preferentially to patients whose main coronary heart disease risk factors are age and hypertension but not hyperlipidemia . By contrast , treatment recommendations based on ARR ensure that lipid-lowering drugs are directed to patients who will derive the most benefit . Furthermore , delaying treatment in younger subjects at high relative risk but not high AR results in their accumulating significant coronary risk in the years before their AR exceeds an arbitrary threshold before lipid-lowering drugs are prescribed Context National guidelines recommend aspirin or statin drugs individually to reduce first coronary heart disease ( CHD )  events , but there are no guidelines about taking both . Contribution The authors used a Markov model to estimate the cost-effectiveness of aspirin , statins , both drugs , or neither in men . In patients with a 10-year risk for CHD of 7.5 % , aspirin alone reduced costs and lengthened life compared with no treatment . Adding a statin cost $ 56200 per additional quality -adjusted life-year at a 7.5 % risk but only $ 42500 at a 10 % risk . Caution s The authors ' analysis was limited to men . Implication s Therapy with aspirin alone is effective and cost-effective in men with an average level of risk for CHD . The addition of a statin is more cost-effective as risk increases . The Editors Aspirin and statin drugs have been shown to be effective for preventing first coronary heart disease ( CHD ) events ( 1 - 3 ) . Systematic review s and meta-analyses suggest that the relative risk reductions with both forms of therapy are similar in magnitude and seem to be independent and relatively constant across the range of underlying risk for CHD ( 2 - 5 ) . The absolute benefit from these treatments seems to be proportional to the patient 's underlying risk for CHD . National treatment guidelines recommend aspirin and statin drugs individually for the primary prevention of cardiovascular events in men who are at increased risk ( 4 , 6 , 7 ) . However , no U.S. guidelines have addressed how these drugs should be used together , and we are unaware of any previous analyses that have reported the cost-effectiveness of these drugs when used in combination for CHD prevention . To help inform clinical and policy decisions about primary CHD prevention , we performed a costutility analysis that examined the use of aspirin therapy , statin therapy , or combination therapy with both drugs in men with various underlying levels of risk for CHD . Methods To examine the cost and utility associated with aspirin and with statin use , we used Microsoft Excel 2002 for Windows ( Microsoft Corp. , Redmond , Washington ) to develop a Markov state-transition model . The model was design ed to simulate cohorts of initially healthy middle-aged men with no history of cardiovascular events and with various levels of 10-year risk for CHD ( Figure 1 ) . Figure 1 . General structure of the Markov model . Base-Case Scenario In our base-case scenario , we compared the effectiveness of 10 years of aspirin therapy , statin therapy , combination therapy with both drugs , and no therapy in 45-year-old men with a 10-year risk for CHD of 7.5 % . After 10 years , both groups adopted the treatment used in the intervention group . Although the differences in therapy were maintained for only 10 years , we examined the effects of these therapies over a lifetime . Model Assumptions All persons were initially healthy and progressed through the model in annual cycles . In each cycle , an individual remained healthy , had an initial cardiovascular event ( angina , myocardial infa rct ion , or stroke ) , experienced adverse effects from therapy ( gastrointestinal bleeding from aspirin or myopathy from statins ) , or died . We assumed that those who had cardiovascular events or adverse events stayed in the subacute state for the remainder of that cycle and then entered a postevent state . Adherence to treatment was assumed to be 100 % in the absence of adverse effects , although the treatment efficacy data were based on the actual rates of adherence in the clinical trials . Persons who had adverse effects from therapy stopped taking the offending medication ; their procession through the model was similar to that of healthy patients after the initial cycle . All costs and outcomes were discounted at 3 % in accordance with current consensus recommendations ( 8) . Model Parameters Model parameters , including base-case values , ranges , and references , are shown in Table 1 ( 1 - 3 , 9 - 29 ) . Table 1 . Base-Case Estimates and Ranges Used in Sensitivity Analyses Noncardiovascular Mortality Age-dependent noncardiovascular mortality rates were estimated from the National Vital Statistics life tables ( 31 ) . Rates were adjusted as the cohort aged over the time horizon of the analysis . Cardiovascular Event Rates Baseline risks for initial cardiovascular events ( myocardial infa rct ion , stroke , angina , and death from CHD ) were drawn from Framingham risk equations by using hypothetical scenarios of nonsmoking , nonhypertensive , nondiabetic men at different levels of risk for CHD ( Appendix Table ) ( 32 ) . Assuming an exponential distribution , we translated these 10-year risks into annual event-related transition probabilities . These probabilities were allowed to change over time to reflect increasing risk for CHD over the time horizon of the analysis . Appendix Table . Sample Baseline Characteristics of 45-Year-Old Men by Risk Level Because we were interested in primary prevention , we did not simulate or examine the details of a patient 's course after a primary , nonfatal event . Instead , we assigned them an increased risk for death , increased costs , and decreased utilities by using data from the literature regarding the average experience of patients after an initial event . The increased relative risk for death after an initial event ( Table 1 ) was drawn from population -based studies in the United Kingdom ( 12 , 16 ) and applied to the general mortality rates from the U.S. life tables to generate the estimated postevent mortality rates . We modified these event rates by assuming that all patients received optimal secondary prevention . Adverse Effects The excess risks for gastrointestinal bleeding with aspirin use and for myopathy with statin use were drawn from systematic review s of r and omized trials and a recent secondary data analysis ( 2 , 26 , 27 ) . Risks for gastrointestinal bleeding and myopathy in untreated patients were assumed to be zero so that only treatment-induced adverse events were counted . Because better data were not available , we estimated the risks for death from aspirin-related gastrointestinal bleeding and statin-induced myopathy and varied them in sensitivity analysis . Patients who had nonfatal adverse effects were not given therapy with alternate agents for primary prevention of CHD . Modeling Stroke Because many r and omized trials of aspirin prophylaxis did not distinguish by stroke type , we had difficulty estimating the precise effect of aspirin on ischemic and hemorrhagic strokes ( 30 ) . To account for this limitation , we used 2 approaches to model the effect of aspirin on stroke . In the base-case analysis , we followed the approach that was used in a recent meta- analysis ( 9 ) by including hemorrhagic stroke and ischemic stroke together in 1 estimate of the effect of aspirin on total stroke ( relative risk for stroke with aspirin , 1.06 ) . In an alternate scenario , we modeled hemorrhagic stroke and ischemic stroke as separate health states . We assumed that aspirin was associated with an excess annual risk of 20 hemorrhagic strokes per 100000 users on the basis of published meta-analyses and that one third of these hemorrhagic strokes would be fatal ( 19 , 30 , 33 ) . We conservatively assumed that aspirin had no effect on ischemic stroke ( 30 ) . The costs and utilities of ischemic stroke and hemorrhagic stroke were also considered separately . Treatment Efficacy We used summary relative risk estimates from existing meta-analyses or relative risks from individual trials to estimate the efficacy of aspirin and statin therapy , either alone or in combination , for preventing CHD events ( 3 , 24 , 29 ) . Where data were limited , we made conservative assumptions . The efficacy of the combined use of aspirin and statins was assumed to be independent on the basis of data from secondary prevention trials ( 5 ) . We did not model the effect of aspirin or statins on initial use of revascularization procedures in the absence of a cardiovascular event . All patients who survived an initial cardiovascular event were assumed to have received secondary preventive therapy with aspirin and a statin or with an alternate agent if  they could not tolerate  aspirin  or  statins . The effect of treatments on all-cause mortality was estimated from meta-analyses of secondary prevention trials ( 18 - 20 ) . Costs We conducted our analysis from the perspective of a third-party payer . State costs ( Table 1 ) , which were derived from data from the published literature and several recent national data bases , are expressed in 2003 dollars . To estimate the costs during the year in which an event occurred , we estimated acute care costs by drawing on data regarding hospital charges from the Healthcare Utilization Project data base and by converting these values to costs . To convert hospital charges to costs , we used the 1999 cost-to-charge ratio value of 0.4501 , which was derived from the Medicare Provider Analysis and Review of short-stay hospitals ( 28 ) . We then used the Medical Consumer Price Index to generate an inflation factor of 1.195 , which was applied to the 1999 cost figure to convert 1999 dollars to 2003 dollars ( 17 ) . In addition to the acute care costs , we assumed that each patient who survived an acute event would also incur one half of the estimated ongoing annual costs of care for the first year . Costs for subsequent years were based on ongoing costs of care that were drawn from the medical literature ( 22 - 25 ) . Drug costs were obtained from the 2003 Red Book average wholesale prices ( 21 ) . For our base-case analysis , we set the annual  statin cost to $ 730 by averaging the Red Book prices of simvastatin ( $ 922 for 10 mg/d ) and lovastatin ( $ 503 for 10 mg/d ) . The base-case cost of aspirin was based on an annual cost of $ 16 for Bayer aspirin ( Bayer Healthcare LLC , Morristown , New Jersey ) . The annual cost of generic aspirin  was estimated at approximately $ 6 ( 21 ) . We varied the costs of each drug over wide ranges in sensitivity analysis . To check our cost estimates , we compared our derived values with other cost estimates OBJECTIVES To determine whether elevated serum cholesterol level is associated with all-cause mortality , mortality from coronary heart disease , or hospitalization for acute myocardial infa rct ion and unstable angina  in persons older than 70 years . Also , to evaluate the association between low levels of  high-density lipoprotein cholesterol  ( HDL-C ) and elevated ratio of serum cholesterol to HDL-C with these outcomes . DESIGN Prospect i ve , community-based cohort study with yearly interviews . PARTICIPANTS A total of 997 subjects who were interviewed in 1988 as part of the New Haven , Conn , cohort of the Established Population for the Epidemiologic Study of the Elderly ( EPESE ) and consented to have blood drawn . MAIN OUTCOME MEASURES The risk factor-adjusted odds ratios of the 4-year incidence of all-cause mortality , mortality from coronary heart disease , and hospitalization for myocardial infa rct ion or unstable angina were calculated for the following : subjects with total serum cholesterol levels  greater than or equal to 6.20 mmol/L ( > or = 240 mg/dL ) compared with subjects with cholesterol levels less than 5.20 mmol/L ( < 200 mg/dL ) ; subjects in the lowest tertile of HDL-C level compared with those in the highest tertile ; and subjects in the highest tertile of the ratio of total serum cholesterol to HDL-C level compared with those in the lowest tertile . RESULTS Elevated total serum cholesterol level , low HDL-C , and high total serum cholesterol to HDL-C ratio were not associated with a significantly higher rate of all-cause mortality , coronary heart disease mortality , or hospitalization for myocardial infa rct ion or unstable angina after adjustment for cardiovascular risk factors . The risk factor-adjusted odds ratio for all-cause mortality was 0.99 ( 95 % confidence interval [ CI ] , 0.56 to 2.69 ) for the group who had cholesterol levels greater than or equal to 6.20 mmol/L ( > or = 240 mg/dL ) compared with the group that had levels less than 5.20 mmol/L ( < 200 mg/dL ) ; 1.00 ( 95 % CI , 0.59 to 1.70 ) for the group in the lowest tertile of HDL-C compared with those in the highest tertile ; and 1.03 ( 95 % CK , 0.62 to 1.71 ) for subjects in the highest tertile of the ratio of total serum cholesterol to HDL-C compared with those in the lowest tertile . CONCLUSIONS Our findings do not support the hypothesis that hypercholesterolemia or low HDL-C are important risk factors for all-cause mortality , coronary heart disease mortality , or hospitalization for myocardial infa rct ion or unstable angina in this cohort of persons older than 70 years OBJECTIVES We sought to describe the incidence , characteristics and survival of out-of-hospital sudden cardiac arrest ( SCA ) in the Maastricht area of The Netherl and s. BACKGROUND Incidence and survival rates of out-of-hospital SCA in different communities are often based on the number of victims resuscitated by the emergency medical services . Our population -based study in the Maastricht area allows information on all victims of witnessed and unwitnessed SCA occurring outside the hospital . METHODS Incidence , patient characteristics and survival rates were determined by prospect ively collecting information on all cases of SCA occurring in the age group 20 to 75 years between January 1 , 1991 and December 31 , 1994 .  Survival rates were related to the site of the event ( at home vs. outside the home ) and the presence or absence of a witness and rhythm at the time of the resuscitation attempt in out-of-hospital SCA . RESULTS Five hundred fifteen patients were included ( 72 % men , 28 % women ) . In 44 % of men and 53 % of women , SCA was most likely the first manifestation of heart disease . In patients known to have had a previous myocardial infa rct ion ( MI ) , the mean interval between the MI and SCA was 6.5 years , with > 50 % having a left ventricular ejection fraction > 30 % . The mean yearly incidence of SCA was 1 in 1,000 inhabitants . Of all deaths in the age groups studied , 18.5 % were sudden . Nearly 80 % of SCAs occurred at home . In 60 % of all cases of SCA a witness was present . Cardiac resuscitation , which was attempted in 51 % of all subjects , result ed overall in 32 ( 6 % ) of 515 patients being discharged alive from the hospital . Survival rates for witnessed SCA were 8 % ( 16 of 208 subjects ) at home and 18 % ( 15 of 85 subjects ) outside the home ( 95 % confidence interval 1 % to 18.8 % ) . CONCLUSIONS The majority of victims of SCA can not be identified before the event . Sudden cardiac arrest usually occurs at home , and the survival of those with a witnessed SCA at home was low compared with that outside the home , indicating the necessity of optimizing out-of-hospital resuscitation , especially in the at-home situation To assess the impact of patient age on the use of diagnostic testing in the management of acute myocardial infa rct ion , the authors review ed the hospital charts of 4,109 patients hospitalized for vali date d acute myocardial infa rct ion in the Worcester , Massachusetts , metropolitan area during selected years between 1975 and 1986 . Older patients were more likely to be female and to have a prior history of angina , hypertension , and diabetes mellitus ( p less than 0.001 ) . Acute myocardial infa rct ions among older patients were more likely to be recurrent , anterior in location , non-Q wave , smaller as reflected by peak creatine kinase levels , and complicated by congestive heart failure , cardiogenic shock , and atrial fibrillation ( p less than 0.001 ) . In-hospital mortality was directly related to increasing patient age ( p less than 0.001 ) . Patterns of utilization of the following diagnostic tests were examined :  Holter monitoring , radionuclide ventriculography , echocardiography , exercise testing , pulmonary artery catheterization , and coronary arteriography .  After adjustment for differences in demographic and clinical characteristics and in-hospital mortality , patients aged 65 years and older were significantly less likely to undergo  exercise testing  than were patients less than age 55 . Patients older than age 75 were significantly less likely to undergo  radionuclide ventriculography , pulmonary artery catheterization , and coronary arteriography  than were younger patients . Sex-specific analyses did not produce results substantially different from those for the overall study population . The results of this community-wide study suggest that among patients hospitalized for acute myocardial infa rct ion , chronologic age may be an independent determinant of utilization patterns of diagnostic testing .  These findings suggest the need for a prospect i ve evaluation of this issue , with an additional emphasis placed on the contributions of functional status and noncardiovascular illness to decision-making in the clinical management of acute myocardial infa rct ion patients We carried out a systematic overview using individual patient data from the seven r and omised trials that have compared a strategy of initial coronary artery bypass graft ( CABG ) surgery with one of initial medical therapy to assess the effects on mortality in patients with stable coronary heart disease ( stable angina not severe enough to necessitate surgery on grounds of symptoms alone , or myocardial infa rct ion ) . 1324 patients were assigned CABG surgery and 1325 medical management between 1972 and 1984 . The proportion of patients in the medical treatment group who had undergone CABG surgery was 25 % at 5 years , 33 % at 7 years , and 41 % at 10 years : 93.7 % of patients assigned to the surgery group underwent CABG surgery . The CABG group had significantly lower mortality than the medical treatment group at 5 years ( 10.2 vs 15.8 % ; odds ratio 0.61 [ 95 % CI 0.48 - 0.77 ] , p = 0.0001 ) , 7 years ( 15.8 vs 21.7 % ; 0.68 [ 0.56 - 0.83 ] , p < 0.001 ) , and 10 years ( 26.4 vs 30.5 % ; 0.83 [ 0.70 - 0.98 ] ; p = 0.03 ) . The risk reduction was greater in patients with left main artery disease than in those with disease in three vessels or one or two vessels ( odds ratios at 5 years 0.32 , 0.58 , and 0.77 , respectively ) . Although relative risk reductions in subgroups defined by other baseline characteristics were similar , the absolute benefits of CABG surgery were most pronounced in patients in the highest risk categories . This effect was most evident when several prognostically important clinical and angiographic risk factors were integrated to stratify patients by risk levels and the extension of survival at 10 years was examined ( change in survival -1.1 [ SE 3.1 ] months in low-risk group , 5.0 [ 4.2 ] months in moderate-risk group , and 8.8 [ 5.4 ] months in high-risk group ; p for trend < 0.003 ) . A strategy of initial CABG surgery is associated with lower mortality than one of medical management with delayed surgery if necessary , especially in high-risk and medium-risk patients with stable coronary heart disease . In low-risk patients , the limited data show a non-significant trend towards greater mortality with CABG Abstract Objective : To estimate the economic efficiency of using pravastatin to prevent the transition from health to cardiovascular disease in men with hypercholesterolaemia . Design : Economic benefit analysis based on data from the West of Scotl and coronary prevention study . Treatment specific hazards of developing cardiovascular disease according to various definitions were estimated . Scottish record linkage data provided disease specific survival . Cost estimates were based on extracontractual tariffs and event specific average lengths of stay calculated from the West of Scotl and coronary prevention study . Subjects : Men with hypercholesterolaemia similar to the subjects in the West of Scotl and coronary prevention study . Main outcome : Cost consequences , the number of transitions from health to cardiovascular disease prevented , the number needed to start treatment , and cost per life year gained . Results : If 10 000 of these men started taking pravastatin  , 318 of them would not make the transition from health to cardiovascular disease ( number needed to treat , 31.4 ) , at a net discounted cost of £ 20 m over 5 years . These benefits imply an undiscounted gain of 2460 years of life , and thus £ 8121 per life year gained , or £ 20 375 per life year gained if benefits are discounted . Restriction to the 40 % of men at highest risk reduces the number needed to treat to 22.5 ( £ 5601 per life year gained ( undiscounted ) and £ 13 995 per life year gained ( discounted ) ) . Conclusions : In subjects without evidence of prior myocardial infa rct ion but who have hypercholesterolaemia , the use of pravastatin yields substantial health benefits at a cost that is not prohibitive overall and can be quite efficient in selected high risk subgroups . Key messages The West of Scotl and coronary prevention study showed that pravastatin can prevent cardiovascular disease in men with hypercholesterolaemia So far , reports have deemed this prevention unjustified due to adverse economic implication s This analysis , based on data from the West of Scotl and coronary prevention study and extensive data from the Scottish record linkage system , shows that using pravastatin in this way is worth considering because of its substantial clinical benefit at a reasonable cost Practitioners must now consider using pravastatin to prevent cardiovascular disease in men with hypercholesterolaemia Increased economic efficiency may be obtained by restricting prevention to patients with additional risk STUDY OBJECTIVE To determine the epidemiology of unwitnessed out-of-hospital cardiac arrest and the factors associated with survival after resuscitation using the Utstein style data collection . METHODS We conducted a prospect i ve cohort study in a 525,000- population city served by a single EMS system comprising a tiered response with physicians in the field . We studied consecutive unwitnessed out-of-hospital cardiac arrests that occurred between January 1 , 1994 , and December 31 , 1995 . We determined survival from cardiac arrest to discharge from hospital and the factors associated with survival . RESULTS Of the 809 patients for whom resuscitation was considered , 205 ( 25.3 % ) had sustained unwitnessed arrests . Cardiac origin of arrest was verified in 52 % of cases . The most common noncardiac causes of arrest were trauma , intoxication , near-drowning , and hanging . In 150 patients ( 73.2 % ) the presenting rhythm was asystole , in 28 ( 13.6 % ) it was pulseless electrical activity , and in 27 ( 13.2 % ) it was ventricular fibrillation . Resuscitation was attempted in 162 cases , 59 ( 36.4 % ) of whom demonstrated return of spontaneous circulation ; 45 ( 27.8 % ) were hospitalized alive , and 8 ( 4.9 % ) were discharged . The survivors represented 6.7 % of all out-of-hospital cardiac arrest survivors during the study period . Survival was most likely if patients presented with pulseless electrical activity ; none of the patients with asystole of cardiac origin survived . Sex ( P = .032 ) , age ( inverse relationship , P = .0004 ) , scene of collapse ( P = .042 ) , and interval from call receipt to arrival of first responders ( P = .004 ) were associated with survival . In a logistic-regression model , near-drowning remained an independent factor of survival ( odds ratio , 15.5 ; 95 % confidence interval , 1.2 to 200 ) . A routine priority dispatching protocol differentiated cardiac arrest patients with survival potential from those who already had irreversible signs of death . CONCLUSION This survey shows that survival after unwitnessed out-of-hospital cardiac arrest is unlikely with an initial response of basic life support alone . Withdrawal of resuscitation should be considered if an adult victim of unwitnessed cardiac arrest is found in asystole and the arrest is of obvious cardiac origin OBJECTIVE : To determine the positive predictive value of ICD-9-CM coding of acute myocardial infa rct ion and cardiac procedures .  METHODS : Using chart- abstract ed data as the st and ard , we examined administrative data from the Veterans Health Administration for a national r and om sample of 5,151 discharges . MAIN RESULTS : The positive predictive value of acute myocardial infa rct ion coding in the primary position was 96.9 % . The sensitivity and specificity of coding were , respectively , 96 % and 99 % for catheterization , 95.7 % and 100 % for coronary artery bypass graft surgery , and 90.3 % and 99.7 % for percutaneous transluminal coronary angioplasty . CONCLUSIONS : The positive predictive value of acute myocardial infa rct ion and related procedure coding is comparable to or better than previously reported observations of administrative data bases BACKGROUND Lowering the blood cholesterol level may reduce the risk of coronary heart disease . This double-blind study was design ed to determine whether the administration of pravastatin to men with hypercholesterolemia and no history of myocardial infa rct ion reduced the combined incidence of nonfatal myocardial infa rct ion and death from coronary heart disease . METHODS We r and omly assigned 6595 men , 45 to 64 years of age , with a mean ( + /- SD ) plasma cholesterol level of 272 + /- 23 mg per deciliter ( 7.0 + /- 0.6 mmol per liter ) to receive pravastatin ( 40 mg each evening ) or placebo .  The average follow-up period was 4.9 years . Medical records , electrocardiographic recordings , and the national death registry were used to determine the clinical end points . RESULTS Pravastatin lowered plasma cholesterol levels by 20 percent and low-density-lipoprotein cholesterol levels by 26 percent , whereas there was no change with placebo . There were 248 definite coronary events ( specified as nonfatal myocardial infa rct ion or death from coronary heart disease ) in the placebo group , and 174 in the pravastatin group ( relative reduction in risk with pravastatin , 31 percent ; 95 percent confidence interval , 17 to 43 percent ; P < 0.001 ) . There were similar reductions in the risk of definite nonfatal myocardial infa rct ions ( 31 percent reduction , P < 0.001 ) , death from coronary heart disease ( definite cases alone : 28 percent reduction , P = 0.13 ; definite plus suspected cases : 33 percent reduction , P = 0.042 ) , and death from all cardiovascular causes ( 32 percent reduction , P = 0.033 ) . There was no excess of deaths from noncardiovascular causes in the pravastatin group . We observed a 22 percent reduction in the risk of death from any cause in the pravastatin group ( 95 percent confidence interval , 0 to 40 percent ; P = 0.051 ) . CONCLUSIONS Treatment with pravastatin significantly reduced the incidence of myocardial infa rct ion and death from cardiovascular causes without adversely affecting the risk of death from noncardiovascular causes in men with moderate hypercholesterolemia and no history of myocardial infa rct ion OBJECTIVES We sought to report the first and repeat events and to separate spontaneous and procedure-related events over two years in the Fast Revascularization during InStability in Coronary artery disease ( FRISC-II ) invasive trial . BACKGROUND The FRISC-II invasive trial compared the long-term effects of an early invasive versus noninvasive strategy , in terms of death and myocardial infa rct ion ( MI ) and the need for repeat hospital admissions and late revascularization procedures in patients with coronary artery disease ( UCAD ) . METHODS In the FRISC-II trial , 2,457 patients with UCAD were r and omized to an early invasive or noninvasive strategy .  RESULTS At 24 month follow-up , there were reductions in mortality ( n = 45 [ 3.7 % ] vs. 67 [ 5.4 % ] ; risk ratio 0.68 [ 95 % confidence interval ( CI ) 0.47 to 0.98 ] ; p = 0.038 ) , MI ( n = 111 [ 9.2 % ] vs. 156 [ 12.7 % ] ; risk ratio 0.72 [ 95 % CI 0.57 to 0.91 ] ; p = 0.005 ) , and the composite end point of death or MI ( n = 146 [ 12.1 % ] vs. 200 [ 16.3 % ] ; risk ratio 0.74 [ 95 % CI 0.61 to 0.90 ] ; p = 0.003 ) in the invasive compared with the noninvasive group . Procedure-related MIs were two to three times more common , but spontaneous ones were three times less common in the invasive than in the noninvasive group . After the first year , there was no difference in mortality ( n = 20 [ 1.7 % ] ) between the two groups and fewer MIs in the invasive group ( p = 0.031 ) . CONCLUSIONS In UCAD , the early invasive approach leads to a sustained reduction in mortality , cardiac morbidity , and the need for repeat hospital admissions and late revascularization procedures . Although the benefits are greatest during the first months , during the second year , cardiac morbidity is lower and the need for hospital care is less in the invasive group
target: At costs lower than $ 0.10 per pill , treating all persons with LDL cholesterol levels greater than 3.4 mmol/L ( > 130 mg/dL ) could be a better strategy .
  Previous cost-effectiveness analyses ( 719 ) show that statin therapy is generally cost-effective for secondary prevention and for high-risk primary prevention but do not focus on population -level impact or average cost-effectiveness across the heterogeneous U.S. population , including such subgroups of patients as those with low risk but very high cholesterol levels .
  Also , it is unclear whether the ATP III approach to risk stratification , in which risk is formally assessed only for patients with 2 or more established risk factors , is the simplest and most cost-effective way of targeting statin therapy .
  The 2004 up date to ATP III ( 3 ) notes that treatment of high-risk subgroups may be useful even when cholesterol levels are low , which suggests that a more purely risk-based approach may be simpler and more cost-effective than the ATP III approach .
background: Context Which lipid-lowering policies with statins are cost-effective ?
  Implication Optimum policies for lipid lowering with statins are highly dependent on statin costs .
  The Editors Coronary heart disease ( CHD ) is the leading cause of death in the United States ( 1 ) .
  Inhibitors of HMG-CoA reductase , known as statins , lower cholesterol and prevent CHD events and mortality ( 2 , 3 ) .
  However , statins are expensive and sometimes cause side effects , which makes it difficult for patients , physicians , and policymakers to decide who should receive them .
  The CHD Policy Model is a mathematical state-transition model of CHD in the United States that can be used to project event rates and costs related to CHD .