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. 2024 Feb 29;74(740):e189-e198.
doi: 10.3399/BJGP.2023.0198. Print 2024 Mar.

Long-term cardiovascular risks and the impact of statin treatment on socioeconomic inequalities: a microsimulation model

Runguo Wu  1 , Claire Williams  2 , Junwen Zhou  2 , Iryna Schlackow  2 , Jonathan Emberson  3 , Christina Reith  2 , Anthony Keech  4 , John Robson  5 , Jane Armitage  3 , Alastair Gray  2 , John Simes  4 , Colin Baigent  3 , Borislava Mihaylova  6 ; CTT Collaboration secretariat CTT Collaboration trialists: A to Z trial (phase Z) AFCAPS/TEXCAPS (AirForce/Texas Coronary Atherosclerosis Prevention Study)ALERT (Assessment of Lescol in Renal Transplantation)ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial)ALLIANCE (Aggressive Lipid-Lowering Initiation Abates New Cardiac Events)ASCOT (Anglo-Scandinavian Cardiac Outcomes Trial)ASPEN (Atorvastatin Study for the Prevention of Coronary Heart Disease Endpoints in Non-Insulin Dependent Diabetes Mellitus)AURORA (A study to evaluate the Use of Rosuvastatin in subjects On Regular haemodialysis: an Assessment of survival and cardiovascular events)CARDS (Collaborative Atorvastatin Diabetes Study)CARE (Cholesterol And Recurrent Events Study)CORONA (Controlled Rosuvastatin Multinational Trial in Heart Failure)4D (Die Deutsche Diabetes Dialyse Studie)GISSI (Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto miocardico) Heart Failure and Prevention trialsHOPE-3HPS (Heart Protection Study)IDEAL (Incremental Decrease in Endpoints through Aggressive Lipid-lowering)JUPITER (Justification for the Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin)LIPID (Long-term Intervention with Pravastatin in Ischaemic Disease)LIPS (Lescol Intervention Prevention Study)Post-CABG (Post-Coronary Artery Bypass Graft Study)PROSPER (Prospective Study of Pravastatin in the Elderly at Risk)PROVE-IT (Pravastatin or Atorvastatin Evaluation and Infection Therapy)SEARCH (Study of Effectiveness of Additional Reductions in Cholesterol and Homocysteine)SPARCL (Stroke Prevention by Aggressive Reduction in Cholesterol Levels)4S (Scandinavian Simvastatin Survival Study)TNT (Treating to New Targets)WOSCOPS (West of Scotland Coronary Prevention Study)Other CTT Collaboration members
Collaborators, Affiliations

Long-term cardiovascular risks and the impact of statin treatment on socioeconomic inequalities: a microsimulation model

Runguo Wu et al. Br J Gen Pract. .

Abstract

Background: UK cardiovascular disease (CVD) incidence and mortality have declined in recent decades but socioeconomic inequalities persist.

Aim: To present a new CVD model, and project health outcomes and the impact of guideline-recommended statin treatment across quintiles of socioeconomic deprivation in the UK.

Design and setting: A lifetime microsimulation model was developed using 117 896 participants in 16 statin trials, 501 854 UK Biobank (UKB) participants, and quality-of-life data from national health surveys.

Method: A CVD microsimulation model was developed using risk equations for myocardial infarction, stroke, coronary revascularisation, cancer, and vascular and non-vascular death, estimated using trial data. The authors calibrated and further developed this model in the UKB cohort, including further characteristics and a diabetes risk equation, and validated the model in UKB and Whitehall II cohorts. The model was used to predict CVD incidence, life expectancy, quality-adjusted life years (QALYs), and the impact of UK guideline-recommended statin treatment across socioeconomic deprivation quintiles.

Results: Age, sex, socioeconomic deprivation, smoking, hypertension, diabetes, and cardiovascular events were key CVD risk determinants. Model-predicted event rates corresponded well to observed rates across participant categories. The model projected strong gradients in remaining life expectancy, with 4-5-year (5-8 QALYs) gaps between the least and most socioeconomically deprived quintiles. Guideline-recommended statin treatment was projected to increase QALYs, with larger gains in quintiles of higher deprivation.

Conclusion: The study demonstrated the potential of guideline-recommended statin treatment to reduce socioeconomic inequalities. This CVD model is a novel resource for individualised long-term projections of health outcomes of CVD treatments.

Keywords: Markov microsimulation model; cardiovascular disease; individual patient characteristics; inequality; quality-adjusted life years; socioeconomic status.

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Conflict of interest statement

Anthony Keech reports research support from Abbott, Amgen, ASPEN, Bayer, Mylan, Novartis, Sanofi, and Viatris; speaker fees from Novartis; and is a Data Safety Monitoring Board member for Kowa. John Robson reports funding from North East London Integrated Care Service. Jane Armitage reports receiving a grant to their research institution from Novartis for the ORION 4 trial of inclisiran. John Simes reports receiving grants for his institution from Amgen, Bayer, BMS, MSD, Pfizer, and Roche; consulting fees from FivepHusion; and is a chair (unpaid) of STAREE DSMB. Colin Baigent reports research grants from Boehringer Ingelheim and Health Data Research UK, and is a chair (unpaid) of a Data Safety Monitoring Board for Merck. All other authors have declared no competing interests.

Figures

Figure 1.
Figure 1.
Risk of vascular endpoints associated with disease-event histories. Adjusted for other individual characteristics at entry and current age. See Supplementary Tables S4–S6 for full details of the risk equations. CRV = coronary revascularisation. CVD = cardiovascular disease. HbA1c = haemoglobin A1C. MI = myocardial infarction.
Figure 2.
Figure 2.
Validation of the CVD model in UK Biobank and Whitehall II Phase 9 participants. Validation covers 12 years in UK Biobank (8 years for incidence diabetes because of stopping follow-up earlier) and 10 years in Whitehall II Phase 9 data (7 years for incidence cancer because of stopping follow-up earlier). CRV = coronary revascularisation. CVD = cardiovascular disease. MI = myocardial infarction.
Figure 3.
Figure 3.
Predicted remaining life expectancy (years) and QALYs for UK Biobank participants. Predicted outcomes presented by CVD history, sex, age, and, for people without CVD history, by 10-year CVD risk (QRISK3). CVD = cardiovascular disease. QALY = quality-adjusted life year. NA = not available.
Figure 4.
Figure 4.
Predicted life years and QALYs in 10 years, 20 years, and over lifetime, by sex, age, and quintile of socioeconomic deprivation in the UK. Predicted remaining life years and QALYs by age, sex, and socioeconomic deprivation quintiles (using Townsend Score) at entry into UK Biobank were standardised to mid-2020 UK population distribution by age, sex, and quintile of socioeconomic deprivation (using Index of Multiple Deprivation quintiles). The bars represent remaining life years or QALYs over lifetime and the areas under the black-dotted lines and red-dotted lines represent QALYs in 10 years and QALYs in 20 years, respectively. CVD = cardiovascular disease. QALY = quality-adjusted life year.
Figure 5.
Figure 5.
Predicted lifetime benefit from UK guideline-recommended statin therapy, by sex, age, and quintile of socioeconomic deprivation in UK. Predicted life years and QALYs gained with full implementation of UK National Institute for Health and Care Excellence guideline-recommended statin therapy at entry into UK Biobank were standardised to mid-2020 UK population distribution by age, sex, and quintile of socioeconomic deprivation (using Index of Multiple Deprivation quintiles). Atorvastatin 20 mg/day was used for individuals without cardiovascular (CVD) history but with a 10-year CVD risk ≥10% and/or type 1 diabetes, an estimated glomerular filtration rate (eGFR) <60 mL/min/1.732, or albuminuria; and atorvastatin 80 mg/day for individuals with CVD history (20 mg in those with eGFR <60 mL/min/1.732). QALY = quality-adjusted life year.
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