Repurposed ramipril, carvedilol, metformin, and generic statins offer low-cost, high-impact cardiovascular prevention

Cardiovascular disease (CVD) remains the leading cause of global mortality, accounting for 19.8 million deaths in 2022 and 32% of all worldwide deaths. Traditional drug development is lengthy and costly, creating a significant gap in accessible, effective prevention strategies. Drug repurposing, which extends approved agents beyond their original indications, offers a high-impact solution by leveraging established safety profiles and reducing development timelines. This approach is crucial for identifying pharmacoeconomically favorable options to improve cardiovascular outcomes and address the global burden of CVD.

This narrative review synthesized evidence from 19 pivotal cardiovascular outcomes trials and current European and American guidelines. It evaluated 13 agents across 8 therapeutic classes for their efficacy and pharmacoeconomic value. Efficacy was quantified using relative and absolute risk reductions, and the number needed to treat or harm. Pharmacoeconomic value was assessed via incremental cost-effectiveness ratio (ICER) in US dollars per QALY (Quality-Adjusted Life Year), integrating mortality in years of life lost and morbidity in years lived with disability. Primary outcomes included all-cause mortality, cardiovascular mortality, major adverse cardiovascular events (MACE), and heart failure hospitalizations.

The review identified three distinct ICER tiers for cardiovascular agents. Low-cost agents (< $20,000/QALY) included ramipril (NNT 28), carvedilol (NNT 29), metformin (NNT 9-15, with highest RRR of 38-42%), and generic statins, all demonstrating robust mortality benefits at negligible cost. Moderate-cost agents ($3,000-$50,000/QALY) encompassed empagliflozin (reducing cardiovascular mortality by 38%, NNT 61), dapagliflozin (NNT 20 in Heart Failure with Reduced Ejection Fraction), liraglutide (NNT 51), semaglutide (NNT 43), and colchicine (NNT 36, primarily for morbidity benefit).

Ramipril, carvedilol, metformin, and generic statins emerged as the most cost-effective, offering substantial mortality benefits for less than $20,000 per QALY. High-cost agents (>$50,000/QALY) were not detailed in the provided abstract snippet but would represent less favorable pharmacoeconomic profiles. The analysis highlights that agents like metformin offer significant relative risk reductions, making them highly impactful, especially in populations with type 2 diabetes.