Novel Treatment Strategies for Secondary Prevention of Cardiovascular Disease: A Systematic Review of Cost-Effectiveness

Clara Marquina Hernandez, Ella Zomer, Sandra Vargas Torres, Sophia Zoungas, Richard Ofori-Asenso, Danny Liew, Zanfina Ademi

Research output: Contribution to journalReview ArticleResearchpeer-review


Background: New pharmacological therapies for the treatment of cardiovascular disease (CVD) have emerged in recent years. The high rates of CVD and the need for long-term treatment to decrease risk factors makes cost-efectiveness crucial for their successful long-term implementation. Objective: This study assessed cost-efectiveness studies of novel pharmacological treatments (ezetimibe, proprotein convertase subtilisin/kexin type 9 [PCSK9] inhibitors, omega-3 polyunsaturated fatty acids [n-3 PUFAs], and the cardiovascular polypill) compared with standard care for the secondary prevention of CVD. Methods: We searched seven databases and the reference list of selected literature reviews for eligible cost-efective analyses (CEA) published between January 2009 and January 2020 that evaluated the above novel treatments versus standard care. Two independent reviewers performed the screening and evaluation in accordance with the Consolidated Health Economic Evaluation Reporting Standards statement. Cost results were adapted to 2018 US dollars (US$) to facilitate comparisons between studies. Consideration of cost-efectiveness was based on the original study criteria. Results: Thirty-two studies were included in this review, most of them adopting a healthcare perspective. Studies evaluating ezetimibe, PCSK9 inhibitors and n-3 PUFAs assessed their addition to standard care compared with standard care alone, while studies analysing the polypill evaluated the replacement of multiple monotherapies for a fxed-dose combination. Ten studies reported on ezetimibe, ffteen evaluated PCSK9 inhibitors, fve focused on n-3 PUFAs and seven on the polypill. From a healthcare perspective, ezetimibe was cost efective in 62.5% of the studies (incremental cost-efectiveness ratios [ICERs] ranged from US$27,195 to US$204,140), n-3 PUFAs in 60% (ICERs from US$57,128 to US$139,082) and the cardiovascular polypill in 100% (ICERs from dominant to US$30,731) compared with standard care. Conversely, only 10% of the studies considered PCSK9 inhibitors cost efective compared with standard care from a healthcare perspective (ICERs ranged from US$231,119 to US$1,223,831). Additionally, ezetimibe was cost efective in 50% of the studies, PCSK9 inhibitors in 33% and the polypill in 50% of the studies adopting a societal perspective. The key model-related parameters predicting costefectiveness included drug cost, time horizon, and the baseline risk of cardiovascular events. Conclusions: Based on current pricing and willingness-to-pay thresholds, most CEA studies considered ezetimibe, n-3 PUFAs and the polypill to be cost efective compared with standard care but not PCSK9 inhibitors for secondary prevention of CVD.
Original languageEnglish
Number of pages19
Publication statusAccepted/In press - 25 Jun 2020

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