目前，指导75岁及以上老年人一级预防证据尚有限，为此，美国学者们在上述年龄人群中开展了一项评估他汀治疗影响和成本-效益研究，结果表明，应用他汀对这类人群进行一级预防具有成本效益，但在特定老年人群中，即使他汀不良反应有小幅度的增加就会抵消其心血管获益。

研究者们应用心血管疾病决策模型，基于低密度脂蛋白胆固醇阈值为4.91 mmol/L (190 mg/dL)、4.14 mmol/L (160 mg/dL)或3.36 mmol/L (130 mg/dL)，存在 或10年风险评分至少为7.5%，对75~94岁老年人群应用他汀一级预防的成本-效益进行了分析。主要转归指标为心肌梗死(MI)、冠心病(CHD)死亡、校正残疾生命-年和成本。

结果显示，美国健康与营养调查中的所有年龄≥75岁的老年人10年风险评分均>7.5%。如果他汀对功能受限或认知损害无影响，所有的一级预防措施均可预防MI和CHD死亡且具有成本效益。如果所有75~94岁老年人群均接受治疗，那么他汀治疗人群将额外增加8百万，同时可预防MI 达105000例 (4.3%)、CHD相关死亡68000例 (2.3%) ，每校正残疾生命-年的增量成本效益为$25200。

敏感性分析结果显示，功能受限或轻度认知受损的相对风险增加1.10 ~1.29才会抵消其心血管获益。

参考文献：

Michelle C. Odden, et al. 21April2015. Ann Intern Med.2015;162(8):533-541. doi:10.7326/M14-1430

21 April 2015

Cost-Effectiveness and Population Impact of Statins for Primary Prevention in Adults Aged 75 Years or Older in the United States

Michelle C. Odden, PhD; Mark J. Pletcher, MD, MPH; Pamela G. Coxson, PhD; Divya Thekkethala, BS; David Guzman, MS; David Heller, MD; Lee Goldman, MD, MPH; and Kirsten Bibbins-Domingo, MD, PhD

See Also:

• Cost-Effectiveness of Statins in Older Adults: Further Evidence That Less Is More

Ann Intern Med. 2015;162(8):533-541. doi:10.7326/M14-1430

Background: Evidence to guide primary prevention in adults aged 75 years or older is limited.

Objective: To project the population impact and cost-effectiveness of statin therapy in adults aged 75 years or older.

Design: Forecasting study using the Cardiovascular Disease Policy Model, a Markov model.

Data Sources: Trial, cohort, and nationally representative data sources.

Target Population: U.S. adults aged 75 to 94 years.

Time Horizon: 10 years.

Perspective: Health care system.

Intervention: Statins for primary prevention based on low-density lipoprotein cholesterol threshold of 4.91 mmol/L (190 mg/dL), 4.14 mmol/L (160 mg/dL), or 3.36 mmol/L (130 mg/dL); presence of diabetes; or 10-year risk score of at least 7.5%.

Outcome Measures: Myocardial infarction (MI), coronary heart disease (CHD) death, disability-adjusted life-years, and costs.

Results of Base-Case Analysis: All adults aged 75 years or older in the National Health and Nutrition Examination Survey have a 10-year risk score greater than 7.5%. If statins had no effect on functional limitation or cognitive impairment, all primary prevention strategies would prevent MIs and CHD deaths and be cost-effective. Treatment of all adults aged 75 to 94 years would result in 8 million additional users and prevent 105 000 (4.3%) incident MIs and 68 000 (2.3%) CHD deaths at an incremental cost per disability-adjusted life-year of $25 200.

Results of Sensitivity Analysis: An increased relative risk for functional limitation or mild cognitive impairment of 1.10 to 1.29 could offset the cardiovascular benefits.

Limitation: Limited trial evidence targeting primary prevention in adults aged 75 years or older.

Conclusion: At effectiveness similar to that in trials, statins are projected to be cost-effective for primary prevention; however, even a small increase in geriatric-specific adverse effects could offset the cardiovascular benefit. Improved data on the potential benefits and harms of statins are needed to inform decision making.

Primary Funding Source: American Heart Association Western States Affiliate, National Institute on Aging, and the National Institute for Diabetes on Digestive and Kidney Diseases.