Primary Prevention With Statins in the Elderly

Mortensen MB, Falk E.
Primary Prevention With Statins in the Elderly. J Am Coll Cardiol 2017;71:85-94.

The following are key points to remember from this review article about primary prevention with statins in the elderly:

  1. Five major North American and European guidelines on statin use in primary prevention have been published since 2013. Guidance on use in the growing elderly population (age >65 years) differs markedly. The differences may in part be related to the year of guideline publication with the American College of Cardiology/American Heart Association (ACC/AHA) in 2013, and National Institute for Health and Care Excellence-United Kingdom (NICE-UK), Canadian Cardiovascular Society (CCS), U.S. Preventive Services Task Force (USPSTF), and European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) in 2016.
  2. The proportion and number of elderly people aged ≥65 years are increasing fast worldwide. At age 65, life expectancy is currently estimated to be >20 years for women and >17 years for men in most high-income countries. The prevalence of coronary heart disease – the most prevalent form of atherosclerotic cardiovascular disease (ASCVD) – in the United States will increase by as much as 43% (about 5 million more) by the year 2030, with an estimated cost of about $70 billion more.
  3. Each of the guidelines share the concept of allocating statins to those at highest risk including diabetics and those at high estimated 10-year risk using different endpoints ranging from major CV events to only fatal ASCVD (ESC/EAS).
  4. Recommended statins based on low-density lipoprotein cholesterol (LDL-C) before treatment is 70-189 mg/dl in the age range of 40-75 years in the ACC/AHA who require a ≥7.5% 10-year risk to be eligible. In contrast, in the NICE-UK, which apply to 30-84 years, high-intensity treatment is recommended regardless of LDL-C if 10-year risk is ≥10%. The ESC/EAS has no clear recommendation because the risk calculator, Systematic COronary Risk Evaluation (SCORE), is not applicable beyond 65 years. This guideline cautions against “uncritical” initiation of statin therapy in those >60 years of age, even if the estimated risk is >10% 10-year risk for fatal CVD. However, they suggest statins should be considered in older adults with all four of the major risk factors.
  5. In contrast, statins would be indicated in elderly individuals with optimal risk factors since they exceed the ACC/AHA 7.5% risk threshold by age 65 (men) or 71 (women) and the NICE-UK 10% QRISK2 risk threshold by age 65 (men) or 68 (women) years.
  6. There are good reasons to believe that the magnitude of benefit with statins may be substantial in elderly people. As the relative risk reduction with statin therapy is similar for those at low and high risk of ASCVD, the absolute benefit of treatment with statins is highly dependent on absolute ASCVD risk. Even in case of a smaller relative benefit with statin therapy in the elderly, the absolute benefit is likely higher because of the higher risk for CVD events.
  7. The decision to initiate primary prevention with statins in people >75 years cannot be based directly on randomized controlled trial evidence. Further, extrapolation of efficacy and safety data from those ≤75 years to those >75 years of age should be done cautiously, considering comorbidity, polypharmacy, potential side effects, and limited life expectancy.
  8. The main goal of primary prevention with statins is to achieve net-benefit from treatment. Potential harm(s) is a crucial part of appropriate decision making. As frailty, comorbidity, and polypharmacy may increase the risk for adverse statin-associated symptoms, the “risk-benefit” balance in the elderly could theoretically tip in favor of withholding statin therapy if such conditions are present.

Keywords: Atherosclerosis, Cholesterol, Comorbidity, Coronary Disease, Diabetes Mellitus, Dyslipidemias, Frail Elderly, Geriatrics, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Polypharmacy, Primary Prevention, Risk Assessment, Risk Factors

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