Objective: To assess the value of different strategies of secondary prevention of CVD and provide pharmacoeconomics evidence for decision making in China, we evaluate the long-term cost-effectiveness of statin, ezetimibe and PCSK9 inhibitors, separately or their combinations for very high-risk patients.

Methods: Based on a network meta-analysis (NMA), we figure out 4 treatment strategy for evaluation. A 6 states Markov model is developed which includes including secondary prevention of CVD, non-fatal stroke recurrence, non-fatal myocardial infarction (MI) recurrence, MI maintenance therapy, stroke maintenance therapy, and death, simulating for 25 years. Model translate probability is gathered from network meta-analysis. Drug cost data is from latest negotiation price and centralized purchase price in 2021 and other cost data is from published studies. Utility data is from previous study. 5% is used as the discount rate. Three times per capita GDP of China ($31316) is used as the willing-to-pay (WTP) threshold. Univariate and probabilistic sensitivity analyses are performed.

Results: Compared with high-dose statin, the ICER for evolocumab therapy is $43321; the ICER for ezetimibe therapy is $19642 per QALY; the ICER for ezetimibe plus evolocumab therapy is $37747 per QALY. With WTP threshold, the probability of cost-effectiveness of evolocumab versus other therapy is 1.5%, while ezetimibe is 56% and ezetimibe plus evolocumab is 9.7%. A reduction in acquisition price of evolocumab by approximately 21.3% is needed to be cost-effective.

Conclusion: Among the current secondary prevention strategies of CVD in very high-risk patients in China, ezetimibe is the most economic advantage. Although the price of evolocumab has been greatly reduced, it still needs to be cut if it wants to be cost-effectiveness.