Cost-Effectiveness of the 2026 ACC/AHA Statin Recommendations for Primary Prevention: A Microsimulation of US Adults Using the PREVENT Equations

Preprint – not peer reviewed. Objectives: The 2026 American College of Cardiology/American Heart Association (ACC/AHA) dyslipidemia guideline adopted the PREVENT equations, lowered statin thresholds and added routes for younger and lower-risk adults. We estimated the cost-effectiveness of these recommendations and of each new eligibility route. Methods: We built an individual-level state-transition model populated with 3,576 participants aged 30–79 years without atherosclerotic cardiovascular disease (ASCVD) or statin use from NHANES 2017–2023, representing 124.6 million US adults. We compared the 2018 and 2026 rules, the 2026 rules without each route, and single PREVENT thresholds from 1% to 20%. Inputs came from trial meta-analyses and published US sources. We used a lifetime horizon, the health care sector perspective, 2025 US dollars and 3% discounting, with deterministic, scenario and probabilistic analyses. Results: The 2026 rules would start 32.1 million more adults on statins, avert 546 ASCVD events per 100,000 people over their lifetimes and cost $91,912 per quality-adjusted life-year (QALY) gained versus the 2018 rules. Treating borderline risk cost $68,225/QALY; the 30-year-risk route cost $402,291/QALY, and the LDL-C 160–189 mg/dL route reduced QALYs. A single 3% PREVENT threshold cost $85,201/QALY. At $120,000/QALY, the 2026 rules were cost-effective versus 2018 in 65% of probabilistic simulations. Results were most sensitive to daily-pill disutility and statin-related diabetes. Conclusions: The 2026 statin expansion is likely cost-effective overall, and treating borderline risk is good value. The 30-year-risk and LDL-C-only routes for low-risk adults are not cost-effective unless statin benefit grows with years of treatment.