Using stress testing to guide primary prevention of coronary heart disease among intermediate-risk patients: a cost-effectiveness analysis.

Background: Noninvasive stress testing might guide the use of aspirin and statins for primary prevention of coronary heart disease, but it is unclear if such a strategy would be cost effective.

Methods And Results: We compared the status quo, in which the current national use of aspirin and statins was simulated, with 3 other strategies: (1) full implementation of Adult Treatment Panel III guidelines, (2) a treat-all strategy in which all intermediate-risk persons received statins (men and women) and aspirin (men only), and (3) a test-and-treat strategy in which all persons with an intermediate risk of coronary heart disease underwent stress testing and those with a positive test were treated with high-intensity statins (men and women) and aspirin (men only). Healthcare costs, coronary heart disease events, and quality-adjusted life years from 2011 to 2040 were projected.

Cost-effectiveness of statin therapy for primary prevention in a low-cost statin era.

Background: With wide availability of low-cost generics, primary prevention with statins has become less expensive. We projected the cost-effectiveness of expanded statin prescribing strategies using low-cost generics and identified conditions under which aggressive prescribing ceases to be cost-effective.

Methods And Results: We simulated expanded statin prescribing strategies with the coronary heart disease policy model, a Markov model of the US population >35 years of age.

Beta-blockers for chest pain associated with recent cocaine use.

Background: Although beta-blockers prevent adverse events after myocardial infarction, they are contraindicated when chest pain is associated with recent cocaine use. Recommendations against this use of beta-blockers are based on animal studies, small human experiments, and anecdote. We sought to test the hypothesis that beta-blockers are safe in this setting.

Prasugrel for acute coronary syndromes: faster, more potent, but higher bleeding risk.

Prasugrel (Effient) has been approved for reducing the risk of thrombotic complications in patients with acute coronary syndromes who are to undergo percutaneous coronary intervention. In a large clinical trial (N Engl J Med 2007; 357:2001-2005), prasugrel was superior to clopidogrel (Plavix), another drug of its class, in this situation. However, bleeding complications were more frequent with prasugrel, and so this drug should be avoided in patients at higher risk of bleeding.