LDL-C Reduction With Lipid-Lowering Therapy for Older Individuals
- In contrast to the attenuation of risk reduction in older persons found in a meta-analysis, this Danish population study found no difference in value for primary prevention in those older compared to younger than 70 years. This could be related to misclassification of persons labeled to have no ASCVD or primary prevention.
- Importantly, the relative risk reduction was 23% for every 1 mmol/L (~40 mg/dL), which is very similar to other population studies.
- The finding evidence for physicians is to consider treating LDL-C for primary prevention in persons ≥70 years, perhaps starting with a lower dose to test for tolerance and titrating to similar targets. The evidence is not adequate to consider the recommendations as evidence-based for guidelines.
Is there a difference in clinical effectiveness of lowering low-density lipoprotein cholesterol (LDL-C) with lipid-lowering therapy for primary prevention of cardiovascular disease among older and younger individuals?
The study was conducted in a Danish nationwide cohort that included individuals aged ≥50 years who had initiated lipid-lowering therapy (statins alone or in combination) between January 1, 2008–October 31, 2017, had no history of atherosclerotic cardiovascular disease (ASCVD) (no hospitalization for ASCVD, use of nitrates, adenosine diphosphate inhibitors, or drugs used for secondary prevention), and had a baseline and a within-1-year LDL-C measurement. The associated risk of major vascular events among older individuals (≥70 years) was determined by hazard ratios (HRs) per 1 mmol/L reduction in LDL-C as compared with younger individuals (<70 years).
For both the 16,035 older and 49,155 younger individuals, the median LDL-C reduction was 1.7 mmol/L. Each 1 mmol/L reduction in LDL-C in older individuals was significantly associated with a 23% lower risk of major vascular events (HR, 0.77; 95% confidence interval [CI], 0.71-0.83), which was equal to that of younger individuals (HR, 0.76; 95% CI, 0.71-0.80; p-value for difference was 0.79). Similar results were observed across all secondary analyses.
In a nationwide cohort study, there is a similar relative clinical benefit of lowering LDL-C for primary prevention of major vascular events in individuals aged ≥70 years as in individuals aged <70 years.
The study was limited to new users of lipid-lowering therapy in routine clinical practice. Evidence from clinical trials of treatments lowering LDL-C has shown that the relative risk of major vascular events is reduced by about 20% for each 1 mmol/L (~40 mg/dL) lowering of LDL-C, which is remarkably similar to the 23% lowering in this Danish population study. Interestingly, the frequency of the physicians prescribing low-, moderate-, and high-intensity lipid-lowering therapy was similar in older and younger groups. Among the limitations includes the likelihood that a significant percentage of those defined as primary prevention had ASCVD.
Keywords: Atherosclerosis, Cholesterol, LDL, Dyslipidemias, Geriatrics, Primary Prevention
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