Evaluation and Treatment of Older Patients With Hypercholesterolemia: A Clinical Review

Perspective:

The following are 10 points to remember about this clinical review:

1. The authors point out that average lifespans are well beyond 80 years of age for many adults residing in western cultures. According to Organization for Economic Co-operation and Development 2010 health data, the mean life expectancy for an 80-year-old man in various European countries varied from 6.3 years (Hungary) to 8.7 years (Greece). In the United States, an 80-year-old man can expect to live another 8.1 years and a woman 9.7 years.

2. Prevention of atherosclerotic cardiovascular disease (ASCVD) may be ineffective or less effective when started late in life.

3. Currently no data exist to recommend additional information from coronary calcium score or carotid intima-media thickness when deciding whether to prescript statin therapy to patients over the age of 80 years.

4. There is some evidence that plasma homocysteine level may correlate well with ASCVD risk in the oldest-old. In the randomized PROSPER (Prospective Study of Pravastatin in the Elderly at Risk) trial comparing placebo and pravastatin in persons ages 70-82 years at baseline, the number needed to treat to prevent one coronary event during 3.2 years was 14.8 (95% confidence interval [CI], 9.3-36.6) for patients with high homocysteine levels, but 64.5 (95% CI, 21.4-∞) for patients with low homocysteine levels.

5. Currently, no randomized clinical trials (RCTs) exist to support use of statins or other lipid-lowering therapy among adults 80 years or older. Findings from 75- to 80-year-old patients enrolled in RCTs and information from observational studies support statin treatment for secondary prevention of ASCVD and probably in patients with diabetes without ASCVD.

6. RCTs have observed reductions in ASCVD events in 75- to 80-year-old patients. Therefore, the American College of Cardiology/American Heart Association guideline supports continuing statin beyond 75 years in persons already taking and tolerating a statin. The guideline also supports starting moderate-intensity statin treatment (in alphabetical order: atorvastatin [10-20 mg], fluvastatin [80 mg], lovastatin [40 mg], pitavastatin [2-4 mg], pravastatin [40 mg], rosuvastatin [5-10 mg], simvastatin [20-40 mg]) in patients ages 75-82 years with clinical ASCVD.

7. There is no recommendation for primary prevention for patients older than 75 years for whom to initiate statin therapy. The authors recommend individualized decisions regarding treatment.

8. There is no specific monitoring recommendation for older patients. However, with increased age, comorbidities, frailty, and polypharmacy, the risk for adverse events increases. The authors recommend that the threshold for monitoring liver enzymes, creatinine kinase, and glucose should be low.

9. Harm from statin drugs is not increased in older patients, so the use of these agents for primary prevention is possible. Because people older than 80 years are biologically heterogeneous with varying life expectancy, may have frailty or comorbid conditions, and may take multiple medications, the decision to treat with statins must be individualized.

10. The authors recommend consideration of various factors when considering statins for older patients. These factors include life expectancy and comorbidities, frailty, risk for ASCVD, and polypharmacy.

Clinical Topics: Dyslipidemia, Noninvasive Imaging, Prevention, Homozygous Familial Hypercholesterolemia, Lipid Metabolism, Nonstatins, Novel Agents, Statins, Echocardiography/Ultrasound

Keywords: Carotid Intima-Media Thickness, Polypharmacy, Life Expectancy, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Fatty Acids, Monounsaturated, Comorbidity, Heptanoic Acids, Creatinine, Hypercholesterolemia, Simvastatin, Primary Prevention, Calcium, Pyrroles, Homocysteine, Secondary Prevention, Indoles, Liver, Pravastatin, Cardiovascular Diseases, Confidence Intervals, Diabetes Mellitus


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