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Simvastatin was cost-effective in lowering cholesterol in coronary heart disease

ACP J Club. 1997 Jul-Aug;127:21. doi:10.7326/ACPJC-1997-127-1-021

Source Citation

Johannesson M, J├Ânsson B, Kjekshus J, et al., for the Scandinavian Simvastatin Survival Study Group. Cost effectiveness of simvastatin treatment to lower cholesterol levels in patients with coronary heart disease. N Engl J Med. 1997 Jan 30;336:332-6.



To determine the cost-effectiveness of lowering cholesterol levels with simvastatin in relation to the age, sex, and pretreatment cholesterol level of patients with coronary heart disease (CHD).


Cost-effectiveness analysis using clinical data from a randomized controlled trial of simvastatin compared with placebo in CHD (Scandinavian Simvastatin Survival Study [4S]). A Markov model was used to estimate the cost-effectiveness of efforts to prevent cardiovascular disease by reducing serum cholesterol levels.


{94 clinical centers in Scandinavia.}*


4444 patients aged 35 to 70 years of age with total cholesterol levels of 5.50 to 8.00 mmol/L (213 to 309 mg/dL) who had a history of angina pectoris or acute myocardial infarction.


{Patients were allocated to simvastatin, 20 to 40 mg/d (n = 2221), or placebo (n = 2223). The dosage was adjusted at 3 and 6 months to achieve a target cholesterol level of 3.0 to 5.2 mmol/L}*

Main cost and outcome measures

Incremental cost per year of life gained with simvastatin therapy. Separate estimates were prepared from men and women, for 3 age groups (35, 59, and 70 years of age), and for 3 pretreatment cholesterol levels (5.50, 6.75, and 8.00 mmol/L). Net costs were calculated by subtracting the savings resulting from the reduction in morbidity associated with coronary causes from the costs of the intervention. Direct and indirect costs were included. Costs and numbers of years of life gained were discounted by 5%. Costs were calculated based on 1995 Swedish prices and converted to U.S. dollars at the 1995 exchange rate (1 U.S. dollar = 7.30 Swedish kronor).

Main results

When only direct costs were included, the cost per year of life gained varied from $3800 for men 70 years of age with cholesterol levels of 8.00 mmol/L to $27 400 for women 35 years of age with cholesterol levels of 5.50 mmol/L. When indirect costs associated with morbidity were also included, simvastatin led to net savings for both men and women aged 35 years of age. In a sensitivity analysis, costs per year of life gained could reach $12 000 for a 59-year-old man and $21 800 for a 59-year-old woman.


Lowering cholesterol levels with simvastatin therapy generated favorable cost-effectiveness ratios among men and women aged 35 to 70 years with coronary heart disease and pretreatment cholesterol levels between 5.50 and 8.00 mmol/L.

Source of funding: Merck Research Laboratories.

For article reprint: Dr. M. Johannesson, Center for Health Economics, Stockholm School of Economics, Box 650a, S-113, 83 Stockholm, Sweden. FAX 46-8-302115.

*Information appeared in The Scandinavian Simvastatin Survival Study (4S). Lancet. 1994;334:1383-9.


Secondary prevention works, but it can be costly. CHD is ubiquitous; the drugs are expensive (simvastatin costs U.S. $40 to $80/mo) and are taken for years, if not decades. Do these drugs represent good value for money?

The best of previously published studies attempting to answer this question suggested that secondary prevention with lovastatin was economically attractive, except in selected subgroups of patients (1). This was a modeling study that used cost and efficacy data that were less than ideal. A recently published descriptive costing study (2) based on the 4S trial also suggested that secondary prevention was economically attractive. It showed that 88% of the cost of drug therapy was offset by reduced hospitalization costs. However, many costs were excluded and no outcome data were incorporated into the analysis.

The study by Johannesson and colleagues strongly supports the conclusions of earlier studies. It is the most comprehensive economic evaluation of this question to date. The chief values of this study are the use of high-quality efficacy data, a model that allows calculation of incremental costs per year of life gained, and reasonably good quality costing data. Like all studies, however, it falls short of perfection; the cost data were not comprehensive or gathered prospectively. The costs of drugs and hospitalization were included, but the costs of outpatient diagnostic testing and treatment were not. Quality of life effects were also excluded. A more important concern is that Scandinavian costs may differ from those in North America or elsewhere in Europe because of differences in practice patterns and the structure of the health care system.

These caveats notwithstanding, the analysis in this study substantially strengthens the evidence for the economic attractiveness of secondary prevention with this class of drugs. Not only are these drugs good medicine, they seem to provide good value for money.

Murray D. Krahn, MD
The Toronto HospitalToronto, Ontario, Canada


1. Goldman L, Weinstein MC, Goldman PA, Williams LW. JAMA. 1991;125:1145-51.

2. Pedersen TR, Kjekshus J, Berg K, et al. Circulation. 1996;93:1796-802.