Pletcher Mark J, Pignone Michael, Jarmul Jamie A, Moran Andrew E, Vittinghoff Eric, Newman Thomas
Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
Department of Medicicine, University of California, San Francisco, San Francisco, CA.
J Am Heart Assoc. 2017 Feb 10;6(2):e004316. doi: 10.1161/JAHA.116.004316.
Benefit-targeted statin prescribing may be superior to risk-targeted statin prescribing (the current standard), but the impact and efficiency of this approach are unclear.
We analyzed the National Health and Nutrition Examination Survey (NHANES) using an open-source model (the Prevention Impact and Efficiency Model) to compare targeting of statin therapy according to expected benefit (benefit-targeted) versus baseline risk (risk-targeted) in terms of projected population-level impact and efficiency. Impact was defined as relative % reduction in atherosclerotic cardiovascular disease in the US population for the given strategy compared to current statin treatment patterns; and efficiency as the number needed to treat over 10 years (NNT, average and maximum) to prevent each atherosclerotic cardiovascular disease event. Benefit-targeted moderate-intensity statin therapy at a treatment threshold of 2.3% expected 10-year absolute risk reduction could produce a 5.7% impact (95% confidence interval, 4.8-6.7). This is approximately equivalent to the potential impact of risk-targeted therapy at a treatment threshold of 5% 10-year atherosclerotic cardiovascular disease risk (5.6% impact [4.7-6.6]). Whereas the estimated maximum NNT is much improved for benefit-targeted versus risk-targeted therapy at these equivalent-impact thresholds (43.5 vs 180), the average NNT is nearly equivalent (24.2 vs 24.6). Reaching 10% impact (half the Healthy People 2020 impact objective, loosely defined) is theoretically possible with benefit-targeted moderate-intensity statins of persons with expected absolute risk reduction >2.3% if we expand age eligibility and account for treatment of all persons with diabetes mellitus or with low-density lipoprotein >190 mg/dL (impact=12.4%; average NNT=23.0).
Benefit-based targeting of statin therapy provides modest gains in efficiency over risk-based prescribing and could theoretically help attain approximately half of the Healthy People 2020 impact goal with reasonable efficiency.
以获益为目标的他汀类药物处方可能优于以风险为目标的他汀类药物处方（当前标准），但这种方法的影响和效率尚不清楚。
我们使用开源模型（预防影响和效率模型）分析了美国国家健康与营养检查调查（NHANES），以比较根据预期获益（以获益为目标）与基线风险（以风险为目标）进行他汀类药物治疗的靶向性在预计人群水平的影响和效率方面的差异。影响定义为与当前他汀类药物治疗模式相比，给定策略在美国人群中动脉粥样硬化性心血管疾病相对降低的百分比；效率定义为预防每例动脉粥样硬化性心血管疾病事件在10年内所需治疗的人数（NNT，平均值和最大值）。在预期10年绝对风险降低2.3%的治疗阈值下，以获益为目标的中等强度他汀类药物治疗可产生5.7%的影响（95%置信区间，4.8 - 6.7）。这大致相当于在10年动脉粥样硬化性心血管疾病风险为5%的治疗阈值下以风险为目标的治疗的潜在影响（5.6%的影响[4.7 - 6.6]）。在这些等效影响阈值下，以获益为目标的治疗与以风险为目标的治疗相比，估计的最大NNT有显著改善（43.5对180），但平均NNT几乎相当（24.2对24.6）。如果我们扩大年龄资格范围并考虑对所有糖尿病患者或低密度脂蛋白>190mg/dL的患者进行治疗，对于预期绝对风险降低>2.3%的人群，使用以获益为目标的中等强度他汀类药物理论上有可能达到10%的影响（大致定义为《健康人民2020》影响目标的一半）（影响 = 12.4%；平均NNT = 23.0）。
基于获益的他汀类药物治疗靶向性在效率上比基于风险的处方略有提高，并且理论上可以以合理的效率帮助实现《健康人民2020》影响目标的大约一半。
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