Abstract Background The aim of this study is to assess the cost-effectiveness of the lipid-lowering arm of the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT-LLA) where patients from seven countries with hypertension and no history of coronary heart disease (CHD) were randomized to receive 10 mg atorvastatin or placebo. Design Economic analysis of a randomized controlled trial. Methods Data on resource use were aggregated for all patients during the entire trial period (median 3.3 years) and multiplied with unit costs for Sweden and the UK. The total number of cardiovascular events and procedures avoided was used as the measure of effectiveness. Results Patients treated with atorvastatin had an additional net costs of 449 € (4114 SEK) in Sweden and 414 € (£260) in the UK, but fewer events per patient (0.097 compared to 0.132). The incremental cost-effectiveness ratios were 12673 € (116119 SEK) and 11693 € (£7349) per event avoided. Conclusion Based on comparisons with the WOSCOPS and 4S studies, atorvastatin at 10 mg to treat patients as in the ASCOT study, appears to be a cost-effective strategy.