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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Patient Evaluation

Unfortunately, outcome data regarding lipid lowering in the elderly are relatively limited, and the ATP III recommendations for older patients are generally extrapolated from data derived from younger populations. However, emerging clinical trial data from studies, such as the Heart Protection Study (HPS),[10] Anglo-Scandinavian Cardiac Outcomes Trial - Lipid Lowering Arm (ASCOT-LLA),[11] and Prospective Study of Pravastatin in the Elderly at Risk (PROSPER),[12] provide valuable insight regarding the treatment of dyslipidemia in the elderly.

The first step in selection of LDL-C lowering therapy is to assess the risk status of the individual. Risk determinants, in addition to LDL-C levels, include the presence of CAD (or coronary heart disease [CHD]), other clinical forms of atherosclerotic disease, cigarette smoking, hypertension, age ( men > 45 years, women > 55 years), low levels of HDL-C (< 40 mg/dL), and family history of premature coronary disease (CAD in a first-degree male relative < 55 years or a first-degree female relative < 65 years). Based on these risk factors, ATP III outlines 3 risk categories that define the goals and modalities of LDL-C lowering therapy (Table 1). CHD refers to myocardial infarction (MI), angina, coronary revascularization procedures, or clinically evident myocardial ischemia. CHD risk equivalents include clinical forms of atherosclerotic disease other than CAD (peripheral arterial disease, abdominal aortic aneurysm, and symptomatic carotid artery disease), diabetes mellitus, and multiple risk factors (2 or more) that confer a 10-year risk for CHD > 20%.

The NCEP has published a report that reflects the additional clinical trial data that have been published since 2001.[13] Of significance, a new treatment goal that was addressed, as a result of the data from the HPS and Pravastain or Atorvastatin and Infection Therapy (PROVE-IT)[14] clinical trials, was the potential importance of reducing the LDL-C level to 70 mg/dL in very high risk patients. Individuals who are considered at very high risk are those with known cardiovascular disease plus (1) multiple major risk factors (especially diabetes mellitus), (2) severely and poorly controlled risk factors (especially continued tobacco use), (3) multiple risk factors for the metabolic syndrome, and (4) patients with acute coronary syndromes. Further data to support lower LDL-C goals are provided by the recently published Treating New Targets (TNT) study.[15] For now, LDL-C reduction to < 70 mg/dL remains a therapeutic option on the basis of clinical trial evidence, whereas a goal LDL-C < 100 mg/dL remains their strong recommendation.

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