An active 79-year-old man develops new-onset substernal chest tightness while playing golf. He has to sit on the ground for the pain to subside. As a result, he avoids his usual daily walk around the golf course. While he remains independent in all activities of daily living, he reports an increase in his weight (body mass index [BMI] = 28 kg/m2). Otherwise, he was never hospitalized in the past 12 months and rates his health as "very good." He takes atenolol 50 mg and aspirin 81 mg on daily basis. He has a history of isolated systolic hypertension, but no history of chronic lung disease, cancer, or congestive heart failure. He has a remote history of smoking, but quit "many years ago." He has no memory problems and still manages his finances.
You order a stress electrocardiogram (ECG) with imaging, which shows diffuse ST-segment depression in the anterolateral leads at peak exercise. His stress echocardiographic images demonstrate anterolateral wall motion abnormalities of moderate severity. A follow-up coronary angiography showed a chronic total occlusion of the right coronary artery and severe diffuse disease in the left anterior descending artery that is not amenable to percutaneous or surgical intervention. He comes back to the clinic for follow-up.
The correct answer is: B. Begin atorvastatin 10 mg daily.
"What is the benefit of statin therapy in the older adult?" is a common question. Prior to answering this question, one should consider the natural history or life expectancy of the older adult with multiple chronic conditions. Work in this area has been done and can be found here. Utilizing the calculator and estimating a 5-year and a 10-year outlook, this patient's estimated five-year mortality according to the Schonberg Index is approximately 9% and estimated ten-year mortality according to the Lee Index is 34-43%. According to these prognostic estimates, he is likely to benefit from lipid-lowering therapy; thus, answer option B is correct. Dyslipidemia is an important modifiable risk factor for secondary prevention of cardiovascular events in older adults with known coronary artery disease (CAD) or a CAD equivalent. According to the 2013 American College of Cardiology/American Heart Association Guidelines on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults, moderate-intensity therapy is recommended (i.e., atorvastatin 10 mg) for secondary risk reduction in adults ages >75 years. These guidelines do not recommend low-density lipoprotein target levels, but empiric treatment with moderate-intensity regimens were emphasized to tailor the patient's individual risk, life expectancy, and functional status.
References
- Lee SJ, Lindquist K, Segal MR, Covinsky KE. Development and validation of a prognostic index for 4-year mortality in older adults. JAMA 2006;295:801-8.
- Schonberg MA, Davis RB, McCarthy EP, Marcantonio ER. Index to predict 5-year mortality of community dwelling adults aged 65 an older using data from the National Health Interview Survey. J Gen Intern Med 2009;24:1115-22.
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