Statins in the Elderly: A Patient‐Focused Approach

Wilmot, Kobina; Khan, Abdullah; Krishnan, Sandeep; Eapen, Danny J.; Sperling, Laurence

doi:10.1002/clc.22338

Cited by 40 publications

(26 citation statements)

References 31 publications

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“…A similar preponderance was reported in an Italian population aged > 75 years, two-thirds of which had an indication for primary prevention [24]. A meta-analysis study showed that statin therapy decreased the risk of myocardial infarction by 39.4% and the risk of stroke by 23.8% in elderly patients with high cardiovascular risk who did not have a history of cardiovascular disease [25]. Also, the Cholesterol Treatment Trialists’ collaboration study showed that high-dose statins in the very elderly group had a more significant effect.…”

Section: Discussionmentioning

confidence: 73%

High-Intensity Statin Therapy Is “Too Much,” Thus Not Indicated for Very Elderly Patients

Lee

Zhang

Jung

et al. 2018

Pulse

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Purpose: Although moderate- to high-intensity statin therapy is increasingly recommended in cardiovascular disease patients, the efficacy and safety in elderly patients have not been proven clearly. Here, we compare the effect of various-intensity statins between elderly and very elderly patients. Methods: 43,870 patients over 65 years old who were treated with statins were screened using electronic medical record data. Results: We evaluated 451 patients in the elderly group aged 65–74 years and 159 patients in the very elderly group over 75 years old. Baseline cholesterol profiles were similar between the 2 groups, but the 10-year atherosclerotic cardiovascular disease (ASCVD) risk was significantly higher in the very elderly (20.9 ± 11.5% vs. 37.2 ± 13.6%, p < 0.001). The reduction rate of low-density lipoprotein (LDL) (–40.2 ± 21.3% vs. –39.3 ± 21.0%, p = 0.634) and the ratio of target LDL attainment (74.2 vs. 79.2%, p = 0.252) were similar between the 2 groups. Low-intensity statins showed comparable LDL cholesterol reduction with moderate-intensity statins both in the elderly and the very elderly groups. The 10-year ASCVD risk reduction was similar between the 2 groups (–3.5 ± 4.9% vs. –3.0 ± 8.4%, p = 0.480), but in the very elderly group, no different ASCVD reduction rate was shown in low- to high-intensity statins (p = 0.784). Only the elderly group showed a significant correlation (r = 0.112, p = 0.017) with LDL reduction and 10-year ASCVD risk. Interestingly, the incidence of adverse drug reaction (ADR) was higher in the very elderly group (4.4%) than in the elderly group (2.7%) and was more frequent in high-intensity statin therapy. Conclusion: The efficacy of statins in LDL reduction was similar between the elderly and very elderly population. However, the benefit of moderate- to high-intensity statins is limited considering potential ADR. Therefore, the stepwise intensification of statin therapy might be necessary for the very elderly in spite of the higher cardiovascular risk.

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Section: Discussionmentioning

confidence: 73%

High-Intensity Statin Therapy Is “Too Much,” Thus Not Indicated for Very Elderly Patients

Lee

Zhang

Jung

et al. 2018

Pulse

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“…To examine whether the hazards associated with LDL cholesterol measurements varied according to age, all statistical models also used an age‐LDL cholesterol interaction within each of the age stratum (66–74 years old versus 75 years and beyond) given uncertainty in the efficacy of statin therapy among patients aged ≥75 years as compared with younger populations 17, 18. Based on the fitted Cox model, the predicted probability of an adverse event within a specified duration of follow‐up could be determined for any patient covariate pattern.…”

Section: Methodsmentioning

confidence: 99%

Projected Real‐World Effectiveness of Using Aggressive Low‐Density Lipoprotein Cholesterol Targets Among Elderly Statin Users Following Acute Coronary Syndromes in Canada

Alter

Koh

et al. 2018

JAHA

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BackgroundThe extent to which outcome benefits may be achieved through the implementation of aggressive low‐density lipoprotein (LDL) cholesterol targets in real world settings remains unknown, especially among elderly statin users following acute coronary syndromes.Methods and ResultsA population‐based cohort study consisting of 19 544 post‐acute coronary syndrome statin‐users aged ≥66 years between January 1, 2017 and March 31, 2014 was used to project the number of adverse outcome events (acute myocardial infarction or death from any cause) that could be prevented if all post‐acute coronary syndrome elderly statin users were treated to 1 of 2 LDL cholesterol target levels (≤50 and ≤70 mg/dL). The number of preventable adverse outcomes was estimated by using model‐based expected event probabilities as derived from Cox Proportional hazards models. In total, 61.6% and 25.5% of the elderly patients met LDL cholesterol targets of ≤70 and ≤50 mg/dL, respectively, based on current management. No more than 2.3 adverse events per 1000 elderly statin users (95% confidence interval: −0.7 to 5.4, P=0.62) could be prevented over 8.1 years if all patients were to be treated from current LDL cholesterol levels to either of the 2 LDL cholesterol targets of 70 or 50 mg/dL.ConclusionsThe number of acute myocardial infarctions or death that could be prevented through the implementation of LDL cholesterol targets with statins is negligible among an elderly post‐acute coronary syndrome population. Such findings may have implications for the applicability of newer agents, such as proprotein convertase subtilisin/kexin type‐9‐ inhibitors.

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“…We excluded patients aged >75 years, for whom the recommendation for high‐intensity statins for coronary ASCVD is reduced from a class I to a class IIa strength of recommendation, depending on provider concerns about adverse effects, patient preference, polypharmacy, and drug–drug interaction 20, 31, 32…”

Section: Methodsmentioning

confidence: 99%

Errors in Electronic Health Record–Based Data Query of Statin Prescriptions in Patients With Coronary Artery Disease in a Large, Academic, Multispecialty Clinic Practice

Shin

Ochuko

Bhatt

et al. 2018

JAHA

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BackgroundWith the recent implementation of the Medicare Quality Payment Program, providers face increasing accountability for delivering high‐quality care. Such pay‐for‐performance programs aim to leverage systematic data captured by electronic health record (EHR) systems to measure performance; however, the fidelity of EHR query for assessing performance has not been validated compared with manual chart review. We sought to determine whether our institution's methodology of EHR query could accurately identify cases in which providers failed to prescribe statins for eligible patients with coronary artery disease.Methods and ResultsA total of 9459 patients with coronary artery disease were seen at least twice at the Emory Clinic between July 2014 and June 2015, of whom 1338 (14.1%, 95% confidence interval 13.5–14.9%) had no statin prescription or exemption per EHR query. A total of 120 patient cases were randomly selected and reviewed by 2 physicians for further adjudication. Of the 120 cases initially classified as statin prescription failures, only 21 (17.5%; 95% confidence interval, 11.7–25.3%) represented true failure following physician review.ConclusionsSole reliance on EHR data query to measure quality metrics may lead to significant errors in assessing provider performance. Institutions should be cognizant of these potential sources of error, provide support to medical providers, and form collaborative data management teams to promote and improve meaningful use of EHRs. We propose actionable steps to improve the accuracy of EHR data query that require hypothesis testing and prospective validation in future studies.

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Statins in the Elderly: A Patient‐Focused Approach

Cited by 40 publications

References 31 publications

High-Intensity Statin Therapy Is “Too Much,” Thus Not Indicated for Very Elderly Patients

High-Intensity Statin Therapy Is “Too Much,” Thus Not Indicated for Very Elderly Patients

Projected Real‐World Effectiveness of Using Aggressive Low‐Density Lipoprotein Cholesterol Targets Among Elderly Statin Users Following Acute Coronary Syndromes in Canada

Errors in Electronic Health Record–Based Data Query of Statin Prescriptions in Patients With Coronary Artery Disease in a Large, Academic, Multispecialty Clinic Practice

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