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Valutazione periodica del rischio cardiovascolare: approccio di prevenzione più conveniente della polipillola

La prescrizione delle statine, ampiamente raccomandata per la prevenzione cardiovascolare, deve essere basata, secondo le recenti linee guida internazionali, sulla stima del rischio CV e su una sua periodica rivalutazione. Un altro approccio proposto per la prevenzione di venti CV è l’uso di una pillola combinata, o polipilla, contenente farmaci ipolipemizzanti e antipertensivi, destinata a persone selezionate solo in base all'età, senza la necessità di valutare il rischio. Questo studio ha confrontato la costo-efficacia dei due approcci, indicando come migliore l’utilizzo della soglia del 20% di rischio cardiovascolare a 10 anni per la prescrizione di farmaci preventivi. L’utilizzo di una soglia più bassa e gli scenari che prevedevano la prescrizione di una polipillola erano efficaci in termini di numero totale di eventi cardiovascolari evitati, ma anche più costosi, con conseguenti costi incrementali non accettabili.

Cost-effectiveness of the polypill versus risk assessment for prevention of cardiovascular disease

Ferket BS, Hunink MG, Khanji M, Agarwal I, Fleischmann KE, Petersen SE

Heart 2017; 103:483-491

OBJECTIVE: There is an international trend towards recommending medication to prevent cardiovascular disease (CVD) in individuals at increasingly lower cardiovascular risk. We assessed the cost-effectiveness of a population approach with a polypill including a statin (simvastatin 20 mg) and three antihypertensive agents (amlodipine 2.5 mg, losartan 25 mg and hydrochlorothiazide 12.5 mg) and periodic risk assessment with different risk thresholds.
METHODS: We developed a microsimulation model for lifetime predictions of CVD events, diabetes, and death in 259 146 asymptomatic UK Biobank participants aged 40-69 years. We assessed incremental costs and quality-adjusted life-years (QALYs) for polypill scenarios with the same combination of agents and doses but differing for starting age, and periodic risk assessment with 10-year CVD risk thresholds of 10% and 20%.
RESULTS: Restrictive risk assessment, in which statins and antihypertensives were prescribed when risk exceeded 20%, was the optimal strategy gaining 123 QALYs (95% credible interval (CI) -173 to 387) per 10 000 individuals at an extra cost of £1.45 million (95% CI 0.89 to 1.94) as compared with current practice. Although less restrictive risk assessment and polypill scenarios prevented more CVD events and attained larger survival gains, these benefits were offset by the additional costs and disutility of daily medication use. Lowering the risk threshold for prescription of statins to 10% was economically unattractive, costing £40 000 per QALY gained. Starting the polypill from age 60 onwards became the most cost-effective scenario when annual drug prices were reduced below £240. All polypill scenarios would save costs at prices below £50.
CONCLUSIONS: Periodic risk assessment using lower risk thresholds is unlikely to be cost-effective. The polypill would become cost-effective if drug prices were reduced.

Heart 2017; 103:483-491