Cost-Effectiveness of Lipid-Lowering Treatments in Young Adults

Ciaran N. Kohli-Lynch, PHD; Brandon K. Bellows, PHARMD; Yiyi Zhang, PHD; Bonnie Spring, PHD; Dhruv S. Kazi, MD; Mark J. Pletcher, MD; Eric Vittinghoff, PHD; Norrina B. Allen, PHD; Andrew E. Moran, MD


J Am Coll Cardiol. 2021;78(20):1954-1964. 

In This Article

Abstract and Introduction


Background: Raised low-density lipoprotein cholesterol (LDL-C) in young adulthood (aged 18–39 years) is associated with atherosclerotic cardiovascular disease (ASCVD) later in life. Most young adults with elevated LDL-C do not currently receive lipid-lowering treatment.

Objectives: This study aimed to estimate the prevalence of elevated LDL-C in ASCVD-free U.S. young adults and the cost-effectiveness of lipid-lowering strategies for raised LDL-C in young adulthood compared with standard care.

Methods: The prevalence of raised LDL-C was examined in the U.S. National Health and Nutrition Examination Survey. The CVD Policy Model projected lifetime quality-adjusted life years (QALYs), health care costs, and incremental cost-effectiveness ratios (ICERs) for lipid-lowering strategies. Standard care was statin treatment for adults aged ≥40 years based on LDL-C, ASCVD risk, or diabetes plus young adults with LDL-C ≥190 mg/dL. Lipid lowering incremental to standard care with moderate-intensity statins or intensive lifestyle interventions was simulated starting when young adult LDL-C was either ≥160 mg/dL or ≥130 mg/dL.

Results: Approximately 27% of ASCVD-free young adults have LDL-C of ≥130 mg/dL, and 9% have LDL-C of ≥160 mg/dL. The model projected that young adult lipid lowering with statins or lifestyle interventions would prevent lifetime ASCVD events and increase QALYs compared with standard care. ICERs were US$31,000/QALY for statins in young adult men with LDL-C of ≥130 mg/dL and US$106,000/QALY for statins in young adult women with LDL-C of ≥130 mg/dL. Intensive lifestyle intervention was more costly and less effective than statin therapy.

Conclusions: Statin treatment for LDL-C of ≥130 mg/dL is highly cost-effective in young adult men and intermediately cost-effective in young adult women.


Raised low density-lipoprotein cholesterol (LDL-C) in young adulthood (aged 18–39 years) increases the risk of atherosclerotic cardiovascular disease (ASCVD) later in life.[1–3] At present, only a small proportion of young adults with raised LDL-C are recommended for lipid-lowering treatment.

Hydroxymethylglutaryl-coenzyme A reductase inhibitors ("statins") substantially lower LDL-C; are cost-effective for primary ASCVD prevention in adults aged 40 to 74 years; and are available in low-cost, generic formulations.[4,5] Intensive lifestyle interventions involving face-to-face or group-based behavioral counseling to improve diet, physical activity, or both alongside regular primary care significantly reduce LDL-C, blood pressure, and body mass index.[6]

The 2018 American College of Cardiology/American Heart Association (ACC/AHA) clinical guideline strongly recommended statins to prevent ASCVD in all adults with LDL-C of ≥190 mg/dL and those aged 40 to 74 years with 10-year ASCVD risk of ≥7.5% or diabetes.[7] The guideline recommended lifestyle modifications for all young adults with elevated LDL-C but restricted statin treatment to young adults with LDL-C of ≥190 mg/dL. The U.S. Preventive Services Task Force has made no specific recommendation for the management of raised LDL-C in young adults.[8]

Expanding statin or intensive lifestyle intervention eligibility for young adults could substantially improve population health.[9] We compared the clinical and economic impact of initiating lipid-lowering strategies for raised LDL-C in young adulthood to 2018 ACC/AHA guideline-recommended standard care using a mathematical model that simulated long-term ASCVD effects of LDL-C exposures and lipid-lowering interventions.