University of Michigan and Veteran Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.
Ann Intern Med. 2010 Jan 19;152(2):69-77. doi: 10.7326/0003-4819-152-2-201001190-00004.
Although treating to lipid targets ("treat to target") is widely recommended for coronary artery disease (CAD) prevention, some have advocated administering fixed doses of statins based on a person's estimated net benefit ("tailored treatment").
To examine how a tailored treatment approach to statin therapy compares with a treat-to-target approach.
Simulated model of population-level effects of treat-to-target and tailored treatment approaches to statin therapy.
Statin trials from 1994 to 2009 and nationally representative CAD risk factor data.
U.S. persons aged 30 to 75 years with no history of myocardial infarction.
Lifetime effects of 5 years of treatment.
Societal and patient.
Tailored treatment based on a person's 5-year CAD risk (simvastatin, 40 mg, for 5% to 15% CAD risk and atorvastatin, 40 mg, for CAD risk >15%) versus treat-to-target approaches that escalate statin dose per National Cholesterol Education Program [NCEP] III guidelines (including an intensive approach that advances treatment whenever intensification is optional by NCEP III criteria).
Quality-adjusted life-years (QALYs).
RESULTS OF BASE-CASE ANALYSIS: Compared with the standard NCEP III approach, the intensive NCEP III approach treated 15 million more persons and saved 570,000 more QALYs over 5 years. The tailored strategy treated a similar number of persons, as did the intensive NCEP III approach, but saved 500,000 more QALYs and treated fewer persons with high-dose statins.
No circumstances were found in which a treat-to-target approach was preferable to tailored treatment.
Model assumptions were based on available clinical data, which included few persons 75 years or older.
A tailored treatment strategy prevents more CAD events while treating fewer persons with high-dose statins than low-density lipoprotein cholesterol-based target approaches. Results were robust, even with assumptions favoring a treat-to-target approach.
Department of Veteran Affairs Health Services Research & Development Service's Quality Enhancement Research Initiative.
尽管针对脂质目标进行治疗（“靶向治疗”）被广泛推荐用于预防冠状动脉疾病（CAD），但有些人主张根据个人的净收益估算值，给予固定剂量的他汀类药物治疗（“量身定制治疗”）。
探讨他汀类药物治疗的量身定制治疗方法与靶向治疗方法相比的效果。
基于他汀类药物治疗的靶向治疗和量身定制治疗方法对人群的影响的模拟模型。
1994 年至 2009 年的他汀类药物试验和具有全国代表性的 CAD 危险因素数据。
年龄在 30 至 75 岁之间、无心肌梗死病史的美国人群。
5 年的治疗效果。
社会和患者。
根据患者 5 年内患 CAD 的风险（辛伐他汀 40mg，用于 5%至 15%CAD 风险，阿托伐他汀 40mg，用于 CAD 风险>15%）量身定制治疗方案，与根据国家胆固醇教育计划（NCEP）III 指南逐步增加他汀类药物剂量的靶向治疗方法（包括在 NCEP III 标准允许的情况下，无论是否强化，都可以进行治疗的强化方法）。
质量调整生命年（QALYs）。
与标准的 NCEP III 方法相比，强化 NCEP III 方法治疗了 1500 多万人，5 年内多挽救了 57 万 QALYs。量身定制的策略治疗了与强化 NCEP III 方法相似数量的患者，但多挽救了 50 万 QALYs，并且治疗了更少的高剂量他汀类药物患者。
没有发现靶向治疗优于量身定制治疗的情况。
模型假设基于现有临床数据，其中包括 75 岁以上的患者较少。
与基于低密度脂蛋白胆固醇的目标方法相比，量身定制的治疗策略可预防更多的 CAD 事件，同时治疗高剂量他汀类药物的患者更少。即使假设有利于靶向治疗，结果也是稳健的。
退伍军人事务部医疗保健研究与发展服务部的质量改进研究倡议。
