LDL Cholesterol and Risk of MI and ASCVD in Adults ≥70 Years

Dec 03, 2020
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Authors:
Mortensen MB, Nordestgaard BG.
Citation:
Elevated LDL Cholesterol and Increased Risk of Myocardial Infarction and Atherosclerotic Cardiovascular Disease in Individuals Aged 70–100 Years: A Contemporary Primary Prevention Cohort. Lancet 2020;396:1644-1652.
Summary By:
Elizabeth A. Jackson, MD, FACC

Quick Takes

  • Elevated LDL cholesterol is associated with increased ASCVD risk among adults ≥70 years of age.
  • The risk of elevated LDL and ASCVD was greatest among those ≥70 years of age.
  • The number needed to treat to prevent ASCVD events, including MI, was lowest for older adults as compared to younger adults (i.e., <70 years).

Study Questions:

Is elevated low-density lipoprotein (LDL) cholesterol associated with increased risk for atherosclerotic cardiovascular disease (ASCVD) in adults ≥70 years of age?

Methods:

Data from the Copenhagen General Population Study (CGPS) were used for the present analysis. CGPS enrolled participants randomly selected through the Danish Civil Registration system to reflect the general Danish population between the ages of 20-100 years, from Copenhagen areas along with the surrounding countryside (with high- and low-income areas). For the present study, participants of white Danish descent were enrolled between 2003 and 2015; those without ASCVD or diabetes at baseline, and who were not taking statins were included. Standard hospital assays were used to measure LDL cholesterol. Primary outcomes of interest included myocardial infarction (MI) and ASCVD.

Results:

A total of 91,131 CGPS participants were included (56% women). Over an average of 7.7 years of follow-up, 1,515 individuals had a first MI, and 3,389 had ASCVD. The highest event rates were observed in those 80-100 years of age. Each 1.0 mmol/L increase in LDL cholesterol was associated with an increased risk for MI in the total population (hazard ratio [HR], 1.34; 95% confidence interval [CI], 1.27-1.41), but highest for those aged 70-100 years. A similar association was seen for ASCVD risk, for each 1.0 mmol/L increase in LDL cholesterol overall (HR, 1.16; 95% CI, 1.12-1.21) and in all age groups, particularly those aged 70-100 years. Among those with significantly elevated LDL (≥5.0 mmol/L [≥193 mg/dl] LDL cholesterol) versus <3.0 mmol/L (<116 mg/dl), risk for MI was significant, including for those aged 80-100 years (HR, 2.99; 95% CI, 1.71-5.23) and in those aged 70-79 years (HR, 1.82; 95% CI, 1.20-2.77). MI and ASCVD events per 1,000 person-years for every 1.0 mmol/L increase in LDL cholesterol were highest in individuals aged 70-100 years, with the number of events lower with younger age. The number needed to treat (NNT) in 5 years to prevent one MI or ASCVD event if all people were given a moderate-intensity statin was lowest for individuals aged 70-100 years, with the NNT increasing with younger age.

Conclusions:

The investigators concluded that adults aged 70-100 years with elevated LDL cholesterol had the highest absolute risk of MI and ASCVD and the lowest estimated NNT in 5 years to prevent one event.

Perspective:

The data suggest that those >70 years of age may benefit from statin use to lower LDL cholesterol. Further study is warranted, particularly among non-European cohorts. Randomized controlled trials to examine the benefits of statin therapy in adults >70 years of age for primary prevention are needed.

Clinical Topics: Dyslipidemia, Geriatric Cardiology, Prevention, Lipid Metabolism, Nonstatins, Novel Agents, Statins

Keywords: Atherosclerosis, Cardiovascular Diseases, Cholesterol, LDL, Geriatrics, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Myocardial Infarction, Primary Prevention, Risk Assessment


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