Most patients undergoing coronary artery bypass grafting (CABG) may reach low-density lipoprotein cholesterol (LDL-C) targets without requiring newer high-cost lipid-lowering agents, according to a modeling analysis published in the Journal of the American Heart Association. The analysis used data from a nationwide cohort of 27,443 US veterans after CABG, with a mean age of 66 years, 10% identifying as Black, and a median LDL-C level of 129 mg/dL (interquartile range [IQR] 95.2–180).

Monte Carlo simulation modeled stepwise initiation of high-intensity statins, ezetimibe, and proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9is) to achieve recommended LDL-C targets. A lifetime Markov model incorporated risks of stroke, myocardial infarction, repeat revascularization, and mortality, while treatment costs and quality-adjusted life years (QALYs) were used to assess cost-effectiveness from the healthcare perspective.

Statin intensification alone enabled 42% of patients to achieve LDL-C targets, while 37% reached targets with ezetimibe included in the treatment sequence. Only 6% required further escalation to bempedoic acid or PCSK9is. Over a projected 30-year period, the stepwise strategy was associated with an estimated gain of 0.8 life years.

The median incremental cost-effectiveness ratio (ICER) was $15,232 per QALY gained (IQR $13,520–17,769), with a 100% probability of cost-effectiveness at willingness-to-pay thresholds above $20,000 compared with observed clinical practice. Overall, the modeled approach indicated that stepwise LLT could limit the need for newer agents while remaining cost-effective at relatively low willingness-to-pay thresholds.