Management Strategies of Dyslipidemia in the Elderly: 2005

Tarek Helmy, MD; Amar D. Patel, MD; Fadi Alameddine, MD; Nanette K. Wenger, MD, FACC, FAHA

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In This Article

Abstract and Introduction

During the past 3 years, the treatment of dyslipidemia has evolved significantly. The impact of recent trial data on management strategies in older patients is especially important, because the elderly segment of the US population continues to grow. Several clinical trials have been completed since the publication of the National Cholesterol Education Program (NCEP) Adult Treatment Panel III guidelines were published in 2001. Recent trial data strongly support the use of lipid-lowering therapy in the elderly population. Although therapeutic lifestyle changes remain highly important, supplementation with lipid-lowering therapy has been shown to reduce the risk of cardiovascular events in both primary and secondary prevention models. Compelling data noted from recent clinical trials have prompted the NCEP to publish an updated report that addresses the significant interim developments.

Given that several epidemiologic studies have identified the elderly population as having a high risk for cardiovascular events, risk-factor modification plays an important role in an attempt to reduce adverse cardiovascular events. Management of dyslipidemia in the elderly is of particular clinical relevance, as the population proportion of the aged is becoming greater over time. Even though dyslipidemia is established as one of the major risk factors for the development of coronary artery disease (CAD) in the elderly, most of these data have been derived from large clinical trials that are mainly comprised of middle-aged patients. However, the association between dyslipidemia and CAD holds true for patients over 65 years of age. Large population-based studies, such as the Established Populations for Epidemiology Studies in the Elderly (EPESE), revealed that an elevated total cholesterol level and low high-density lipoprotein cholesterol (HDL-C) level are associated with increased risk of cardiovascular mortality, especially in men.[1,2] Conversely, lower cholesterol levels (as seen in vegetarians) were associated with a lower incidence of CAD and cardiovascular death in patients between the ages of 75 and 84 when compared with nonvegetarians with higher cholesterol levels.[3]

Despite a growing body of evidence regarding the benefits of aggressive reduction of cholesterol levels, older patients with either documented dyslipidemia or significant risk factors for the development of CAD are often underdiagnosed or undertreated. Data from a study conducted in Canada demonstrated that among hospitalized patients at high risk for cardiovascular events, risk-factor assessment and modification were suboptimal, particularly for women and elderly patients.[4] This may be the result of a paucity of evidence regarding the impact of treatment on delaying the progression of atherosclerotic disease in response to screening-guided therapy, concerns of the increased likelihood of adverse events or drug interactions, or doubts regarding the cost-effectiveness of lipid-lowering drug therapy in the elderly population. The National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) III report recommends that all adults with blood total cholesterol values above 200 mg/dL be evaluated and that those with elevated low-density lipoprotein cholesterol (LDL-C) levels be treated.[5] Furthermore, no upper age limit should be defined for lipid-lowering interventions in patients with CAD or at increased risk for CAD.[5] Based on the NCEP guidelines, about one third of elderly men and one half of elderly women have elevated cholesterol levels warranting intervention.[6] ATP III expands the indications for intensive cholesterol-lowering therapy in clinical practice. Elevated triglyceride (TG) levels are also considered to be an independent risk factor for developing CAD. Although this was initially difficult to demonstrate in individual studies (mainly due to multiple variables and confounding risk factors),[7] a recent meta-analysis validated the importance of TG as a cardiovascular risk factor.[8,9] As such, the ATP III guidelines now include TG level reduction as a secondary target after LDL-C reduction has been achieved.

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