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Journal of Peking University (Health Sciences) ›› 2022, Vol. 54 ›› Issue (3): 443-449. doi: 10.19723/j.issn.1671-167X.2022.03.008

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Effectiveness of statin treatment strategies for primary prevention of cardiovascular diseases in a community-based Chinese population: A decision-analytic Markov model

Chao GONG1,Qiu-ping LIU1,Jia-min WANG1,Xiao-fei LIU1,Ming-lu ZHANG1,Han YANG1,Peng SHEN2,Hong-bo LIN2,Xun TANG1,*(),Pei GAO1,3,*()   

  1. 1. Department of Epidemiology and Biostatistics, Peking University School of Public Health, Beijing 100191, China
    2. Yinzhou District Center for Disease Control and Prevention, Ningbo 315101, Zhejiang, China
    3. Center of Real-World Evidence Evaluation, Peking University Clinical Research Institute, Beijing 100191, China
  • Received:2022-02-07 Online:2022-06-18 Published:2022-06-14
  • Contact: Xun TANG,Pei GAO E-mail:tangxun@bjmu.edu.cn;peigao@bjmu.edu.cn
  • Supported by:
    National Natural Sciences Foundation of China(81973132);National Key Research and Development Program of China(2020YFC2003503)

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Abstract:

Objective: To evaluate the effectiveness of statin treatment strategies based on risk assessment for the primary prevention of cardiovascular diseases by the Western guidelines in a community-based Chinese population from economically developed areas using data from the Chinese electronic health records research in Yinzhou (CHERRY) study. Methods: A Markov model was used to evaluate the effectiveness of the following statin treatment strategies, including: (1) usual care without cardiovascular risk assessment(Strategy 0); (2) using the World Health Organization (WHO) non-laboratory-based risk charts with statin treatment for high-risk group (risk ≥ 20%) (Strategy 1); (3) using the WHO laboratory-based risk charts with statin treatment for high-risk group (risk ≥ 20%) (Strategy 2); and (4) using the Prediction for Atherosclerotic cardiovascular disease Risk in China (China-PAR) model with statin treatment for high-risk group (risk ≥ 10%, Strategy 3). According to the guidelines, adults in the medium-risk group received lifestyle intervention, and adults in the high-risk group received life-style intervention and statin treatment under these strategies. The Markov model simulated different strategies for ten years (cycles) using parameters from the CHERRY study, published data, meta-analyses and systematic reviews for Chinese. The number of cardiovascular events or deaths, as well as the number need to treat (NNT) with statin per cardiovascular event or death prevented, were calculated to compare the effectiveness of different strategies. One-way sensitivity analysis on the uncertainty of incidence rate of cardiovascular diseases, and probabilistic sensitivity analysis on the uncertainty of hazard ratios of interventions were conducted. Results: Totally 225 811 Chinese adults aged 40-79 years without cardiovascular diseases at baseline were enrolled. In contrast to the usual care without risk assessment-based statin treatment strategy, Strategy 1 using the WHO non-laboratory-based risk charts could prevent 3 482 [95% uncertainty interval (UI): 2 110-4 661] cardiovascular events, Strategy 2 using the WHO laboratory-based risk charts could prevent 3 685 (95%UI: 2 255-4 912) events, and Strategy 3 using the China-PAR model could prevent 3 895 (95%UI: 2 396-5 181) events. NNTs with statin per cardiovascular event prevented were 22 (95%UI: 14-54), 21 (95%UI: 14-52), and 27 (95%UI: 17-67), respectively. Strategy 3 could prevent more cardiovascular events, while Strategies 1 and 2 required fewer numbers need to treat with statin per cardiovascular event prevented. The results were consistent in the sensitivity analyses. Conclusion: The statin treatment strategies based on risk assessment for the primary prevention of cardiovascular diseases recommended by the Western guidelines could achieve substantive health benefits in adults from developed areas of China. Using the China-PAR model for cardiovascular risk assessment could prevent more cardiovascular diseases while using the WHO risk charts seems more efficient.

Key words: Cardiovascular diseases, Primary prevention, Statin, Markov model

CLC Number: 

  • R181.2

Figure 1

Markov model diagram for statin treatment strategy based on cardiovascular risk assessment CVD, cardiovascular diseases; P1, probability from CVD-free status to alive with CVD status; P2, probability from CVD-free status to CVD death status; P3, probability from CVD-free status to non-CVD death status; P4, probability to stay alive without CVD; P5, probability from alive with CVD status to CVD death status; P6, probability from alive with CVD status to non-CVD death status; P7, probability to stay alive with CVD."

Table 1

Parameters and data sources in the Markov model"

Items Incidence of cardiovascular diseases Mortality of cardiovascular diseases Data sources
40-49 years 50-59 years 60-69 years 70-79 years 40-49 years 50-59 years 60-69 years 70-79 years
Probability (1/100 000)
  Strategy 0, n Estimated from the current study
    Non-stratified 179 468 1 186 3 039 13 30 99 677
  Strategy 1, n Estimated from the current study
    Low risk 178 442 827 0 13 28 45 0
    Medium risk 361 667 1 305 2 448 40 49 117 458
    High risk 0 1 142 1 892 3 352 0 265 203 793
  Strategy 2, n Estimated from the current study
    Low risk 173 410 744 0 12 24 49 0
    Medium risk 687 791 1 296 2 367 67 65 107 421
    High risk 0 1 036 2 131 3 397 0 149 234 814
  Strategy 3, n Estimated from the current study
    Low risk 167 378 812 2 042 12 24 60 103
    Medium risk 449 701 1 209 2 659 40 43 96 578
    High risk 375 1 067 1 743 3 334 34 105 172 763
HR of intervention effects, ${\bar x}$±s
  Weight control 0.93±0.05 0.93±0.16 Meta-analysis[9]
  Smoking cessation 0.85±0.02 0.72±0.13 Meta-analysis[10] and cohort study[11]
  Salt reduction 0.81±0.08 0.66±0.14 Meta-analysis[12]
  Statin treatment 0.76±0.07 0.76±0.07 Clinical trial[13]

Table 2

Baseline characteristics of study population"

Characteristics Men (n=105 550) Women (n=120 261) P value
Age/years, ${\bar x}$±s 55.50 ± 9.90 54.48 ± 9.54 < 0.001
Urban, n (%) 32 394 (30.69) 39 332 (32.71) < 0.001
Smoker, n (%) 40 148 (38.04) 1 619 (1.35) < 0.001
Family history of ASCVD, n (%) 789 (0.75) 688 (0.57) < 0.001
Diabetes mellitus, n (%) 9 166 (8.68) 10 408 (8.65) 0.804
SBP/mmHg, ${\bar x}$±s 131.82 ± 15.17 130.60 ± 16.03 < 0.001
DBP/mmHg, ${\bar x}$±s 82.85 ± 9.56 81.32 ± 9.61 < 0.001
BMI/(kg/m2), ${\bar x}$±s 23.35 ± 2.68 23.23 ± 2.91 < 0.001
Waist circumference/cm, ${\bar x}$±s 83.45 ± 7.37 79.38 ± 7.73 < 0.001
Total cholesterol/(mmol/L), ${\bar x}$±s 4.80 ± 0.96 5.02 ± 0.97 < 0.001
HDL-C/(mmol/L), ${\bar x}$±s 1.25 ± 0.34 1.34 ± 0.32 < 0.001
LDL-C/(mmol/L), ${\bar x}$±s 2.77 ± 0.81 2.89 ± 0.83 < 0.001

Table 3

Comparisons of effectiveness by different strategies with statin treatment"

Strategy 1 vs. Strategy 0 Strategy 2 vs. Strategy 0 Strategy 3 vs. Strategy 0 Strategy 2 vs. Strategy 1 Strategy 3 vs. Strategy 1 Strategy 3 vs. Strategy 2
Total numbers for assessment 225 811 225 811 225 811
Total numbers for lifestyle intervention 66 781 69 433 80 418
Total numbers for statin treatment 15 806 17 815 24 568
QALYs gained 7 570 (4 843, 9 507) 7 881 (5 120, 9 853) 7 939 (5 118, 9 966) 311 (246, 365) 369 (245, 473) 57 (-12, 114)
Cardiovascular events could be prevented 3 482 (2 110, 4 661) 3 685 (2 255, 4 912) 3 895 (2 396, 5 181) 203 (143, 254) 413 (279, 525) 211 (137, 271)
Cardiovascular deaths could be prevented 1 019 (516, 1 328) 1 044 (538, 1 356) 1 040 (523, 1 357) 25 (19, 29) 21 (8, 29) -4 (-15, 3)
All deaths could be prevented 1 230 (748, 1 554) 1 286 (800, 1 615) 1 278 (782, 1 614) 55 (45, 63) 47 (31, 61) -8 (-18, 0)
NNT with statin per cardiovas- cular event prevented 22 (14, 54) 21 (14, 52) 27 (17, 67) 0 (-2, 0) 5 (3, 14) 5 (3, 16)
NNT with statin per cardiovas- cular death prevented 66 (46, 128) 69 (48, 131) 104 (72, 205) 3 (2, 3) 38 (26, 77) 35 (24, 74)
NNT with statin per all death prevented 51 (37, 85) 52 (38, 83) 78 (56, 131) 0 (-1, 1) 26 (19, 47) 26 (18, 48)

Figure 2

One-way sensitivity analyses on cardiovascular events by different incidence rates of cardiovascular diseases Strategy 0, usual care without cardiovascular risk assessment; Strategy 1, statin treatment strategy based on cardiovascular risk assessment using the WHO non-laboratory-based model; Strategy 2, statin treatment strategy based on cardiovascular risk assessment using the WHO laboratory-based model; Strategy 3, statin treatment strategy based on cardiovascular risk assessment using the China-PAR model. WHO, World Health Organization; China-PAR, prediction for atherosclerotic cardiovascular disease risk in China."

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