{"id":"46053","type":"article","url":"https://hartvaat.nl/2026/04/07/kosteneffectiviteit-van-stapsgewijze-lipidenverlaging-na-coronaire-bypasschirurg/","title":"Kosteneffectiviteit van stapsgewijze lipidenverlaging na coronaire bypasschirurgie","title_en":"Assessing the Cost Effectiveness of an Incremental Lipid-Lowering Therapy Approach After Coronary Artery Bypass Grafting Using Nationwide Data.","category":"cholesterol","category_label":"Cholesterol","professions":["cardioloog","internist"],"tags":[],"journal":"Journal of the American Heart Association","doi":"10.1161/JAHA.124.040272","source_url":"https://doi.org/10.1161/JAHA.124.040272","authors":["Salil V Deo","Giorgio Ciminata","Gauranga Mahalwar","Pedro R V O Salerno","David A McAllister","Yakov E Elgudin","Ariela Orkaby","Salim Virani","Stephen Fremes","Sanjay Rajagopalan","Naveed Sattar","Jill P Pell"],"significance":6,"published":"2026-07-18","source_date":"2026-04-07","image":"","kennis":["https://hartvaat.nl/kennis/lipiden/statines-overzicht/","https://hartvaat.nl/kennis/lipiden/lipidenverlaging-stappenplan/"],"congress":"","summary_en":"Lipid-lowering therapy (LLT) is important after coronary artery bypass grafting (CABG), but cost limits wider use of PCSK9 inhibitors and newer agents. In a nationwide cohort of US veterans after CABG, the investigators used Monte Carlo simulations to model stepwise initiation of high-intensity statins, ezetimibe and a PCSK9 inhibitor toward LDL targets, followed by a lifetime Markov model with events (stroke, myocardial infarction, revascularisation and death). The aim was to compare the cost-effectiveness of this stepwise LLT approach with observed practice from the health-care perspective. The study provides a framework to inform targeted, stepwise use of costlier lipid-lowering agents.","created":"2026-07-03T20:27:11Z","updated":"2026-07-04T19:26:57Z","licence":"Citeer vrij, met bronvermelding en een link naar hartvaat.nl (de url van het record). Samenvattingen zijn redactioneel werk van HartVaat; de oorspronkelijke publicaties blijven van hun uitgevers (doi). Geen medisch advies.","body_markdown":"Lipidenverlagende therapie (LLT) is belangrijk na coronaire bypasschirurgie (CABG), maar de kosten beperken het bredere gebruik van PCSK9-remmers en nieuwere middelen. Op een landelijk cohort van Amerikaanse veteranen na CABG modelleerden de onderzoekers met Monte-Carlosimulaties de stapsgewijze opbouw van hoog-intensieve statines, ezetimibe en een PCSK9-remmer naar de LDL-streefwaarde, gevolgd door een levenslang Markov-model met events (beroerte, infarct, revascularisatie en sterfte). Doel was de kosteneffectiviteit van deze getrapte LLT-aanpak te vergelijken met de waargenomen praktijk vanuit het zorgperspectief. De studie biedt een raamwerk om de gerichte, getrapte inzet van duurdere lipidenverlagers te onderbouwen.","abstract_original":"BACKGROUND: Lipid-lowering therapy (LLT) is important for risk reduction for patients after coronary artery bypass grafting. Cost limits the wider use of PCSK9 (proprotein convertase subtilsin/kexin type 9) inhibitors (PCSK9is) and newer drugs. Hence, mathematical modeling was performed on a nationwide cohort of US veterans post coronary artery bypass grafting to understand the need for expensive drugs like PCSK9is and the cost effectiveness of this model was evaluated. METHODS: First, Monte Carlo simulations were used to model the stepwise initiation of high-intensity statins, ezetimibe, and PCSK9i therapy for each patient to lower their low-density lipoprotein cholesterol levels to recommended targets. Next, a lifetime Markov model was constructed with stroke, myocardial infarction, repeat revascularization, and mortality rates obtained our study cohort of nationwide US veterans post coronary artery bypass grafting. LLT treatment costs and quality adjusted life years were used to determine the cost effectiveness of this stepwise LLT approach versus observed clinical practice from the health care perspective. Probabilistic models were fit and results for cost effectiveness reported using incremental cost-effectiveness ratio per quality adjusted life year gained over the lifetime. RESULTS: For 27 443 US veterans post- coronary artery bypass grafting (mean age 66 years, 10% Black) with a median low-density lipoprotein cholesterol 129 (interquartile range, 95.2-180) mg/dL, the 42% and 37% reached target LLT by statin intensification only and including ezetimibe, respectively. Only 6% required bempedoic acid or PCSK9is after the preceding steps. Such stepwise LLT reduction projected 0.8 life years gained over the 30-year period. With a median incremental cost-effectiveness ratio of percent 15 232 (interquartile range, 13 520-17 769) per quality adjusted life year gained, this stepwise approach reached 100% probability for being cost effective (compared with observed clinical practice) at willingness-to-pay thresholds >$20 000. CONCLUSIONS: Few patients needed bempedoic acid or PCSK9is when simulating stepwise LLT with high-intensity statins and ezetimibe. Such an approach was observed as cost effective at very low willingness-to-pay thresholds."}