The cost‐effectiveness of coronary calcium score‐guided statin therapy initiation for Australians with family histories of premature coronary artery disease

Prasanna Venkataraman, Amanda L Neil, Geoffrey K Mitchell, Tony Stanton, Stephen Nicholls, Andrew M Tonkin, Gerald F Watts and Thomas H Marwick
Med J Aust 2023; 218 (5): . || doi: 10.5694/mja2.51860
Published online: 20 March 2023


Objectives: To compare the cost‐effectiveness of coronary artery calcium (CAC) score‐guided statin therapy criteria and American College of Cardiology/American Heart Association (ACC/AHA) guidelines (10‐year pooled cohort equation [PCE] risk ≥ 7.5%) with selection according to Australian guidelines (5‐year absolute cardiovascular disease risk [ACVDR] ≥ 10%), for people with family histories of premature coronary artery disease.

Study design, setting: Markov microsimulation state transition model based on data from the Coronary Artery calcium score: Use to Guide management of Hereditary Coronary Artery Disease (CAUGHT‐CAD) trial and transition probabilities derived from published statin prescribing and adherence outcomes and clinical data.

Participants: 1083 people with family histories of premature coronary artery disease but no symptomatic cardiovascular disease.

Main outcome measures: Relative cost‐effectiveness over fifteen years, from the perspective of the Australian health care system, compared with usual care (Australian guidelines), assessed as incremental cost‐effectiveness ratios (ICERs), with a notional willingness‐to‐pay threshold of $50 000 per quality‐adjusted life‐year (QALY) gained.

Results: Applying the Australian guidelines, 77 people were eligible for statin therapy (7.1%); with ACVDR 5‐year risk ≥ 2% and CAC score > 0, 496 people (46%); with ACVDR 5‐year risk ≥ 2% and CAC score ≥ 100, 155 people (14%); and with the ACC/AHA guidelines, 256 people (24%). The ICERs for CAC‐guided selection were $33 108 (CAC ≥ 100) and $53 028 per QALY gained (CAC > 0); the ACC/AHA guidelines approach (ICER, $909 241 per QALY gained) was not cost‐effective. CAC score‐guided selection (CAC ≥ 100) was cost‐effective for people with 5‐year ACVDR of at least 5%.

Conclusion: Expanding the number of people at low to intermediate CVD risk eligible for statin therapy should selectively target people with subclinical atherosclerosis identified by CAC screening. This approach can be more cost‐effective than simply lowering treatment eligibility thresholds.

  • 1 Baker Heart and Diabetes Institute, Melbourne, VIC
  • 2 Menzies Research Institute Tasmania, University of Tasmania, Hobart, TAS
  • 3 The University of Queensland, Brisbane, QLD
  • 4 Monash Medical Centre, Monash University, Melbourne, VIC
  • 5 Monash University, Melbourne, VIC
  • 6 The University of Western Australia, Perth, WA



This investigation was supported by a National Health and Medical Research Council project grant (GRT1080582) and a Postgraduate Scholarship for Prasanna Venkataraman (GRT1169357).

Competing interests:

No relevant disclosures.

  • 1. National Vascular Disease Prevention Alliance. Guidelines for the management of absolute cardiovascular disease risk. 2012. https://irp.cdn‐ (viewed Dec 2022).
  • 2. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease. Executive summary: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. J Am Coll Cardiol 2019; 74: 1376‐1414.
  • 3. Lloyd‐Jones DM, Braun LT, Ndumele CE, et al. Use of risk assessment tools to guide decision‐making in the primary prevention of atherosclerotic cardiovascular disease: a special report from the American Heart Association and American College of Cardiology. Circulation 2019; 139: e1162‐e1177.
  • 4. Blaha MJ, Whelton SP, Al Rifai M, et al. Comparing risk scores in the prediction of coronary and cardiovascular deaths: Coronary Artery Calcium Consortium. JACC Cardiovasc Imaging 2021; 14: 411‐421.
  • 5. Gupta A, Lau E, Varshney R, et al. The identification of calcified coronary plaque is associated with initiation and continuation of pharmacological and lifestyle preventive therapies: a systematic review and meta‐analysis. JACC Cardiovasc Imaging 2017; 10: 833‐842.
  • 6. Näslund U, Ng N, Lundgren A, et al; VIPVIZA trial group. Visualization of asymptomatic atherosclerotic disease for optimum cardiovascular prevention (VIPVIZA): a pragmatic, open‐label, randomised controlled trial. Lancet 2019; 393: 133‐142.
  • 7. Hamilton‐Craig CR, Chow CK, Younger JF, et al. Cardiac Society of Australia and New Zealand position statement executive summary: coronary artery calcium scoring. Med J Aust 2017; 207: 357‐361.‐society‐australia‐and‐new‐zealand‐position‐statement‐executive‐summary
  • 8. Jennings GL, Audehm R, Bishop W, et al. National Heart Foundation of Australia position Statement on coronary calcium scoring for primary prevention of cardiovascular disease in Australia. Med J Aust 2021; 214: 434‐439.‐heart‐foundation‐australia‐position‐statement‐coronary‐artery‐calcium
  • 9. Venkataraman P, Kawakami H, Huynh Q, et al; CAUGHT‐CAD investigators. Cost‐effectiveness of coronary artery calcium scoring in people with a family history of coronary disease. JACC Cardiovasc Imaging 2021; 14: 1206‐1217.
  • 10. Marwick TH, Whitmore K, Nicholls SJ, et al; CAUGHT‐CAD Investigators. Rationale and design of a trial to personalize risk assessment in familial coronary artery disease. Am Heart J 2018; 199: 22‐30.
  • 11. McClelland RL, Jorgensen NW, Budoff M, et al. 10‐Year coronary heart disease risk prediction using coronary artery calcium and traditional risk factors: derivation in the MESA (Multi‐Ethnic Study of Atherosclerosis) with validation in the HNR (Heinz Nixdorf Recall) study and the DHS (Dallas Heart Study). J Am Coll Cardiol 2015; 66: 1643‐1653.
  • 12. Dufouil C, Beiser A, McLure LA, et al. Revised Framingham stroke risk profile to reflect temporal trends. Circulation 2017; 135: 1145‐1159.
  • 13. Australian Institute of Health and Welfare. General record of incidence of mortality (GRIM) data (AIHW cat. no. PHE 229).‐expectancy‐deaths/grim‐books/contents/about (viewed Dec 2020).
  • 14. Venkataraman P, Huynh Q, Nicholls SJ, et al; CAUGHT‐CAD investigators. Impact of a coronary artery calcium‐guided statin treatment protocol on cardiovascular risk at 12 months: results from a pragmatic, randomised controlled trial. Atherosclerosis 2021; 334: 57‐65.
  • 15. National Heart Foundation. Economic cost of acute coronary syndrome in Australia: the cost to governments. 2018.‐_Cost_of_ACS_to_Governments—Individuals_and_Families_August_2018.pdf (viewed Jan 2022).
  • 16. Independent Hospital Pricing Authority. National hospital data collection report: public sector, round 21 financial year 2016–17; appendix tables, version 9.0. 12 Mar 2019.‐08/Round%2021%20NHCDC%20Report%20‐%20Appendix%20Tables.xlsx (viewed Jan 2023).
  • 17. Australian Institute of Health and Welfare. Health expenditure Australia 2017–18 (AIHW cat. no. HWE 77; Health and welfare expenditure no. 65). 2019.‐e50f‐4895‐be1f‐b475e578eb1b/aihw‐hwe‐77.pdf (viewed Jan 2022).
  • 18. Australian Bureau of Statistics. Consumer price index, Australia. Reference period Dec 2019. 29 Jan 2020.‐indexes‐and‐inflation/consumer‐price‐index‐australia/dec‐2019#main‐contributors‐to‐change (viewed Jan 2021).
  • 19. Edney LC, Haji Ali Afzali H, Cheng TC, Karnon J. Estimating the reference incremental cost‐effectiveness ratio for the Australian health system. Pharmacoeconomics 2018; 36: 239‐252.
  • 20. Australian Bureau of Statistics. 2033.0.55.001. Census of population and housing: Socio‐Economic Indexes for Areas (SEIFA), Australia, 2016. 27 Mar 2018. (viewed Jan 2023).
  • 21. Venkataraman P, Stanton T, Liew D, et al. Coronary artery calcium scoring in cardiovascular risk assessment of people with family histories of early onset coronary artery disease. Med J Aust 2020; 213: 170‐177.‐artery‐calcium‐scoring‐cardiovascular‐risk‐assessment‐people‐family
  • 22. Ferket BS, Hunink MG, Khanji M, et al. Cost‐effectiveness of the polypill versus risk assessment for prevention of cardiovascular disease. Heart 2017; 103: 483‐491.
  • 23. Denissen SJ, van der Aalst CM, Vonder M, et al. Impact of a cardiovascular disease risk screening result on preventive behaviour in asymptomatic participants of the ROBINSCA trial. Eur J Prev Cardiol 2019; 26: 1313‐1322.
  • 24. Schilling C, Knight J, Mortimer D, et al. Australian general practitioners initiate statin therapy primarily on the basis of lipid levels; New Zealand general practitioners use absolute risk. Health Policy 2017; 121: 1233‐1239.
  • 25. Rozanski A, Gransar H, Shaw LJ, et al. Impact of coronary artery calcium scanning on coronary risk factors and downstream testing the EISNER (early identification of subclinical atherosclerosis by noninvasive imaging research) prospective randomized trial. J Am Coll Cardiol 2011; 57: 1622‐1632.
  • 26. Bengtsson A, Norberg M, Ng N, et al. The beneficial effect over 3 years by pictorial information to patients and their physician about subclinical atherosclerosis and cardiovascular risk: results from the VIPVIZA randomized clinical trial. Am J Prev Cardiol 2021; 7: 100199.
  • 27. Ofori‐Asenso R, Jakhu A, Zomer E, et al. Adherence and persistence among statin users aged 65 years and over: a systematic review and meta‐analysis. J Gerontol A Biol Sci Med Sci 2018; 73: 813‐819.
  • 28. National Heart Foundation of Australia. Guidelines for the diagnosis and management of hypertension in adults. 2016.‐835a‐4fcf‐96f5‐88d770582ddc/PRO‐167_Hypertension‐guideline‐2016_WEB.pdf (viewed Dec 2022).


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