Echocardiographic quantification of atherosclerosis leads to cost-effective treatment with statins.

OBJECTIVE: Use of statins in prevention of atherosclerosis is effective but expensive. Patient selection gains wider public attention as medication costs in the US and Europe augment by 8% to 10% per year. We examined different clinical risk stratification strategies, particularly focusing on echocardiographic atherosclerosis quantification, for their impact on event reduction and cost-effectiveness in statin treatment. METHODS AND RESULTS: In a prospective, consecutive cohort of 336 patients referred to non-invasive cardiac examination, risk stratification was done by various combinations of risk factors and noninvasive atherosclerosis quantification. Atherosclerotic burden was determined through measuring "aortic elastance" by transthoracic echocardiogram, a validated non-invasive method. Cardiovascular events were recorded at a mean follow-up of one year. Echocardiographically determined atherosclerosis severity and event history, especially in combination, yielded the best selection strategies for statin treatment over a broad range of predetermined funding or required event reductions, surpassing conventional cardiovascular risk factors. From 26.8 statin-preventable events/1000 patients/year (assuming all patients treated), the best selection strategies could avoid: 24 with 66% of the cost for statin treatment (atherosclerosis and age criteria), 20.1 with <50% of the budget, 12.2 with <30% of the budget or 9.6 with <15% of the budget (using combinations of atherosclerosis and prior events), while conventional strategies without echo quantification of atherosclerosis were inferior. CONCLUSION: Non-invasive echocardiographic quantification of atherosclerosis improves efficiency and cost-effectiveness in statin treatment.

Use of B-type natriuretic peptide for the management of women with dyspnea.

In studies with predominately male patients, B-type natriuretic peptide (BNP) levels have been shown to be helpful in the evaluation and management of patients who present with acute dyspnea. The effect of BNP levels on the management of women has not been defined. This study evaluated a predefined subgroup of 190 women included in a prospective randomized controlled study of BNP testing for emergency diagnosis of acute dyspnea. Patients were randomly assigned to a diagnostic strategy with (n = 93, BNP group) or without (n = 97, control group) the use of BNP levels provided by a rapid bedside assay. Women differed significantly from men in baseline characteristics, symptoms, signs, and final discharge diagnoses. The use of BNP levels decreased the need for hospital admission (73% vs 86%, p = 0.034) and intensive care (12% vs 23%, p = 0.048). Median time to discharge was 6 days in the BNP group versus 10 days in the control group (p = 0.023). Total cost of treatment was $4,781 in the BNP group (95% confidence interval 3,854 to 5,708) versus $6,843 in the control group (95% confidence interval 5,611 to 8,074, p = 0.009). In-hospital mortality rates were 4% in the BNP group and 10% in the control group (p = 0.165). Thus, used in conjunction with other clinical information, rapid measurement of BNP decreased time to discharge and total cost of treatment in women who presented with acute dyspnea.