The prevalence and management of familial hypercholesterolemia in patients with acute coronary syndrome in the Polish tertiary centre: Results from the TERCET registry with 19,781 individuals.

BACKGROUND AND AIMS: The prevalence of familial hypercholesterolemia (FH) is high among patients with stable coronary artery disease (CAD). However, data on FH on admission among patients with acute coronary syndrome (ACS) are still relatively scarce. Therefore, we aimed to assess the prevalence, lipid-lowering therapy and short- and long-term outcomes in patients with FH among ACS patients. METHODS AND RESULTS: The investigation was performed in a cohort of 19,781 consecutive patients from the TERCET Registry. There were 7319 patients admitted with ACS: 3085 due to STEMI, 2256 due to NSTEMI, and 1978 due to UA. The stable CAD group (n = 12,462) was considered the reference group. Based on the personal and familial history of premature cardiovascular disease and LDL cholesterol concentration, the Dutch Lipid Clinic Network (DLCN) algorithm was used for FH diagnosis. The overall occurrence of probable/definite FH and possible FH was 1.2% and 13.5% respectively. Among patients with ACS, 1.6% had probable/definite FH and 17.0% possible FH. The highest occurrence of FH was observed in the STEMI subgroup (20.6%). Patients with definite and probable FH had higher 30-day mortality than patients without FH (8.2% and 3.8% vs. 2.0%, respectively; p = 0.0052). No significant differences were observed between the FH groups in the 12-, 36- and 60-month follow-up. Propensity-score matching analysis showed that definite/probable FH patients had significantly higher all-cause mortality at 36- and 60-month follow-up in comparison to non-FH subjects (11.4% vs. 4.8% and 19.2% vs. 7.2%, respectively; p ≤ 0.021 for both). CONCLUSIONS: The prevalence of FH according to the DLCN criteria in the Polish very high-risk population is significantly higher in patients with ACS than in patients with sCAD. FH is a cause of increased all-cause mortality in the long-term follow-up.

Cost-effectiveness analysis of the use of a high-intensity statin compared to a low-intensity statin in the management of patients with familial hypercholesterolaemia.

OBJECTIVES: To estimate, using probabilistic decision-analytic modelling techniques, the cost effectiveness of treating familial hypercholesterolaemia (FH) patients with high-intensity statins compared to treatment with low-intensity statins. For the purpose of this economic analysis, and based on their known differences, statins were categorised as high intensity if they produce greater LDL-cholesterol reductions than simvastatin 40 mg (e.g., simvastatin 80 mg and appropriate doses of atorvastatin and rosuvastatin or combination of statins + ezetimibe). METHODS: A lifetime Markov model was developed to estimate the incremental cost per quality adjusted life year (QALY) of treating a hypothetical cohort of 1000 FH patients aged between 20 and 70 years. Baseline coronary heart disease risks reported in the NICE TA 94 on statins, and age-adjusted risk of cardiovascular disease reported in the FH population, were used to populate the model. A meta-analysis estimate of the reduction in cardiovascular events from using high-intensity compared with low-intensity statins was obtained from published trials. Results were interpreted using a cost-effectiveness threshold of pound20 000/QALY. RESULTS: Fewer cardiovascular events and deaths were predicted to occur in the group treated with higher-intensity statins, and the incremental cost-effectiveness ratio (ICER) was estimated at pound11 103/QALY. The ICER remained below the pound20 000 threshold for 20-39-year-olds and 40-59-year-olds, but rose above this threshold in individuals aged over 60 years. One-way sensitivity analysis showed that results were most sensitive to variation in treatment effect on mortality and the cost of high-intensity statins. CONCLUSIONS: Modelling demonstrates that high-intensity statins are cost-effective for the treatment of younger FH patients. If, as is likely, the relative price of high-intensity statins fall in the future as they come off patent, then their cost effectiveness will improve further.

Cholesterol screening and life assurance.

OBJECTIVES: To examine how insurance companies assess proposals for life assurance from applicants with raised cholesterol concentrations and to determine the excess mortality rating applied. DESIGN: Survey of 49 companies underwriting term life assurance. SETTING: United Kingdom. SUBJECTS: Four fictional men aged 30 seeking 20 year term policies paying benefit only on death. Two had total cholesterol concentrations of 6.4 and 8.1 mmol/l but no other cardiovascular risk factors; one was overweight, hypertensive, smoked 20 cigarettes daily, and had a total cholesterol concentration of 8.1 mmol/l; and one had possible familial hypercholesterolaemia and a total cholesterol concentration of 10.7 mmol/l after treatment. MAIN OUTCOME MEASURE: Percentage excess mortality rating. RESULTS: All companies used explicit criteria to assess the mortality risk associated with hyperlipidaemias, and 47 companies applied the same criteria to men and women. No excess mortality rating was imposed on an applicant with a total cholesterol concentration of 6.4 mmol/l, but a small excess was applied to an applicant with a concentration of 8.1 mmol/l (median excess 50%, range 0-75%). When multiple cardiovascular risk factors were present the same concentration of 8.1 mmol/l resulted in a substantial excess (median 135%, range 50-200%). A smaller but more variable excess was applied to an applicant with possible familial hypercholesterolaemia (median 75%, range 0-200%). CONCLUSIONS: Despite considerable differences among companies in the excess mortality ratings applied, increases in term life assurance premiums are likely to be restricted to patients with severe hypercholesterolaemia, in particular those with familial hypercholesterolaemia. In the absence of other cardiovascular risk factors milder hypercholesterolaemia is unlikely to result in higher premiums.