Centre for Health Informatics, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK.
Manchester Centre for Health Economics, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK.
Pharmacoepidemiol Drug Saf. 2020 Jun;29(6):644-652. doi: 10.1002/pds.5023. Epub 2020 May 11.
A patient is eligible for statins in England if they have a 10-year risk of cardiovascular disease >10%. We hypothesize that if statin discontinuation rates are high it may be better to delay statin initiation until patients are at a higher risk, to maximize the benefit of the drug.
A four-state health state transition model was used to assess the optimal time to initiate statins after a risk assessment, in order to prevent the highest number of cardiovascular events, for a given risk profile (age, gender, risk) and adherence rate. A Clinical Practice Research Datalink dataset linked to Hospital Episodes Statistics and Office for National Statistics was used to inform the transition probabilities in this model, taking into account observed statin discontinuation and re-continuation patterns.
Our results suggest, if statins are initiated in a cohort of 50-year old men with a 10% 10-year risk, we prevent 4.78 events per 100 individuals. If we wait 10 years to prescribe, at which point 10-year risk scores are at 20%, we prevent 5.45 events per 100 individuals. If the observed discontinuation rate was reduced by a sixth, third or half in the same cohort, we would prevent 7.29, 9.01 or 10.22 events per 100 individuals.
In certain scenarios, extra cardiovascular disease events could be prevented by delaying statin initiation beyond a risk of 10% until reaching a age (59 for men, 63 for women), based on statin discontinuation rates in England. The optimal time to initiate statins was driven by age, not by cardiovascular risk.
在英格兰，如果患者的心血管疾病 10 年风险>10%，则符合使用他汀类药物的条件。我们假设，如果他汀类药物停药率较高，那么最好等到患者的风险更高时再开始使用他汀类药物，以最大限度地发挥药物的效益。
使用四状态健康状态转移模型来评估在风险评估后开始使用他汀类药物的最佳时间，以预防给定风险概况（年龄、性别、风险）和依从率下最高数量的心血管事件。使用临床实践研究数据链接到医院发病统计和国家统计局的数据集来为该模型中的转移概率提供信息，同时考虑到观察到的他汀类药物停药和重新开始使用的模式。
我们的研究结果表明，如果在一群年龄为 50 岁、10 年风险为 10%的男性中开始使用他汀类药物，我们可以预防每 100 人中发生 4.78 起事件。如果我们等待 10 年再开始处方，此时 10 年风险评分达到 20%，我们可以预防每 100 人中发生 5.45 起事件。如果在同一队列中观察到的停药率降低六分之一、三分之一或一半，我们将预防每 100 人中发生 7.29、9.01 或 10.22 起事件。
在某些情况下，通过延迟他汀类药物的起始时间，超过 10%的风险，直到达到一个年龄（男性为 59 岁，女性为 63 岁），可以根据英格兰的他汀类药物停药率来预防更多的心血管疾病事件。开始使用他汀类药物的最佳时间是由年龄决定的，而不是心血管风险。
