Stockholm -- Europe has become a danger zone for cardiovascular disease, with the CHD epidemic now reaching the highest mortality and morbidity of any geographic area in the world, according to Dr James Shepherd (University of Glasgow, Scotland, UK).

Cardiovascular disease eclipses every other disease as the major killer worldwide, Shepherd said. He cited figures from the World Health Organization, which found 15 million of 52 million deaths worldwide attributable to cardiovascular disease.

In a session on health economy at the XIIth International Symposium on Atherosclerosis, Shepherd raised the issue of the cost-effectiveness of intervention strategies, particularly statin drugs, to reduce cardiovascular death in the face of galloping cost increases.

On the basis of 200 000 patient years of experience in clinical trials using the statins, Shepherd called these drugs "an extraordinarily safe group of compounds." He also said the statins have been shown to work across a wide range of risk factors, reducing the 5-year risk of MI by as much as 40%.

The statins also work in conjunction with other drugs, from aspirin and beta blockers to ACE inhibitors and calcium antagonists, "so it is inappropriate, in clinical terms, to try to disengage all these agents from the benefits they produce as a cohesive whole," Shepherd said. He concluded, "We should be treating patients with a global treatment strategy."

The question he now hears as he travels around the world is: "how much is this going to cost and can we afford it?"

As principal investigator of the West of Scotland Coronary Prevention Study (WOSCOPS), Shepherd said he had requests from the government for information about the economics of the trial. Armchair economists estimated it would cost about £160 000 to stop one heart attack.

"What they had forgotten was we didn't just stop heart attacks, we stopped strokes, we stopped hospitalizations, we stopped CABGs, we stopped angina and we stopped all sorts of transitions from health to disease," Shepherd said.

Based on WOSCOPS and other trials, the response of governments has been to question the cost of treatment, he emphasized. On the other hand, some economists have found that secondary prevention of MI with a statin is not much more expensive than the use of beta blockers in disease prevention, while primary prevention with a statin is less expensive than the use of stents.

One of the unfortunate problems with health economics is that there is not yet a gold standard for calculating costs, Shepherd said.

In the UK, health economists examined the question of which patients should receive treatment, based on the WOSCOPS cohort. In the cohort, the risk of an MI was 1.5% per year. The economists calculated that 11.5% of the so-called healthy Scottish population would need to be treated in order to deal with that kind of risk, a strategy they considered to be "far too expensive."

The UK health authorities came up with the notion that individuals who have a 3% per year risk of having a heart attack should be treated, according to Shepherd.

But he cautioned physicians against using the concept of risk unthinkingly. "Age is a driving force in incremental risk and may lead to treating the elderly in the population to the exclusion of the younger," he said.

Shepherd cited the Long-Term Intervention with Pravastatin in Ischemic Disease (LIPID) study as a case in point. The trial showed that the risk of any event in the 31- to 64-year-old age range was substantially lower than in the 65- to 75-year-old age range. While 33 individuals in the younger group had to be treated to avoid one event, only 24 in the older group had to be treated.

"In economic terms, there is benefit to treating the elderly who are at high levels of risk," Shepherd said. "But if the availability of resources is limited to the elderly, the epidemic of CHD which is growing in the younger age range will never be eliminated."

Shepherd called for a secondary prevention strategy, but one that is bolstered by a population strategy. "The scope of these two strategies, driven in parallel, will depend on the economics of the community and be driven by social and political pressure in that community," he said.

Pat Phillips
www.athero.org