Myths and Facts Concerning the Use of Statins in Very Old Patients

Abstract

As population grows old, the number of persons at risk of cardiovascular events also grows. Though octogenarians form a small percentage of the general population their absolute risk of coronary and cerebrovascular disease is high, but there is still some doubt as to whether high plasma cholesterol levels increase vascular risk in this age group, as published data are conflicting. There is evidence that elevated plasma cholesterol increases the risk of coronary artery disease in older adults, and an inverse linear relationship was found between HDL cholesterol levels and the risk of mortality from ischemic heart disease in all age groups. The relationship between total plasma cholesterol and the risk of death from ischemic stroke is weak in younger populations and is even lower in people between 70 and 89 years, and is inverse for hemorrhagic stroke. However, studies showed that statin treatment lowers the risk of ischemic stroke, independently of age. Statins are underused in the elderly, perhaps because of lack of perception of the real vascular risk of older adults, concerns about statin efficacy or safety in this population, or the increase of comorbidities and polypharmacy which could affect adherence to drug-treatment. Trials designed to address this issues are urgently needed, in order to be able to make evidence-guided decisions on lipid management of the elderly.

Statin Use Following Hospitalization Among Medicare Beneficiaries With a Secondary Discharge Diagnosis of Acute Myocardial Infarction

“…Although statin therapy would not benefit patients who were already dying from another cause, not prescribing treatment for many patients with AMI listed as a secondary diagnosis may not be appropriate. Among patients with CVD, statin use has been shown to benefit older patients (Pravastatin or Atorvastatin Evaluation and Infection Therapy Thrombolysis in Myocardial Infarction 22 trial), patients with chronic kidney disease (Treating to New Targets trial), and patients with prior stroke (Stroke Prevention by Aggressive Reduction in Cholesterol Levels trial), and current guidelines recommend secondary prevention for all AMIs . Our findings are consistent with prior reports that older patients and those with history of hypertension, stroke, and renal dysfunction are less likely to receive statin prescriptions after AMI .…”

“…Low statin use among Medicare beneficiaries with AMI as a secondary discharge diagnosis observed in this study might in part reflect physicians’ evaluations of the benefit–harm tradeoff for patients with multiple comorbidities or a history of statin intolerance . Although statin therapy would not benefit patients who were already dying from another cause, not prescribing treatment for many patients with AMI listed as a secondary diagnosis may not be appropriate.…”

“…Low statin use among Medicare beneficiaries with AMI as a secondary discharge diagnosis observed in this study might in part reflect physicians' evaluations of the benefit-harm tradeoff for patients with multiple comorbidities or a history of statin intolerance. 24,25 Although statin therapy would not benefit patients who were already dying from another cause, not prescribing treatment for many patients with AMI listed as a secondary diagnosis may not be appropriate. Among patients with CVD, statin use has been shown to benefit older patients (Pravastatin or Atorvastatin Evaluation and Infection Therapy Thrombolysis in Myocardial Infarction 22 trial), patients with chronic kidney disease (Treating to New Targets trial), and patients with prior stroke (Stroke Prevention by Aggressive Reduction in Cholesterol Levels trial), and current guidelines recommend secondary prevention for all AMIs.…”

Current Drug Treatment of Hyperlipidemia in Older Adults

“…As much of the data for primary prevention in older adults come from subgroup analyses of RCTs that are usually not pre-specified in the trial design, caution is warranted when interpreting the results [24]. The PROS-PER trial, which was included in both of the aforementioned meta-analyses, is the only study that was specifically designed to assess statin efficacy for primary and secondary prevention in older adults between the ages of 70 and 82 [19].…”

“…The PROS-PER trial, which was included in both of the aforementioned meta-analyses, is the only study that was specifically designed to assess statin efficacy for primary and secondary prevention in older adults between the ages of 70 and 82 [19]. To date, no evaluation has been made of the subgroup of patients aged[80 years from RCTs; therefore, statin use for primary prevention in individuals aged [80 years is still uncertain [24].…”