Statins in Very Elderly Adults (Debate)

Neil J. Stone, MD, MACP, FACC; Sunny Intwala, MD; Dan Katz, BA

Disclosures

J Am Geriatr Soc. 2014;62(5):943-945. 

In This Article

Abstract and Introduction

Introduction

Topic: Should patients 85 and older take statins?

Two carefully done systematic reviews suggest that statin therapy may be appropriate for very elderly adults (≥85). First, the compelling per-person meta-analysis of the Cholesterol Treatment Trialists shows that statin therapy in randomized clinical trials (RCTs) significantly reduces major vascular events per mmol/L decrease in low-density lipoprotein cholesterol (LDL-C) in those aged 75 and older.[1] Also, a high-quality Cochrane review found that statin therapy for those in primary prevention (at risk of atherosclerotic cardiovascular disease (ASCVD) events (e.g., heart attack, stroke)) over a wide age range is safe and effective,[2] but the decision to use statins in individuals aged 85 and older should not be reflexive. Robust RCT evidence for the benefit of statins in primary prevention of ASCVD in individuals aged 85 and older is lacking. For primary prevention, a shared decision-making model emphasizing the understanding that choices are available and must be considered carefully with strong patient input to decision-making is therefore suggested.[3] Alternatively, the strong case for statin therapy should be highlighted for secondary ASCVD prevention. Two anecdotes highlight these points. A physician in his late 80s walked into the office with canes in each hand requesting a second opinion regarding statin therapy. His LDL-C level was approximately 150 mg/dL, and he had been given a statin prescription but had no history of ASCVD. He reasoned that, if he experienced any muscular weakness from a statin, his independence and quality of life would be curtailed greatly. His doctors agreed, and 5 years later, he is still active and grateful for the shared decision-making. At approximately the same time, an active 86-year-old woman developed an acute coronary syndrome, had a stent placed in her left anterior descending coronary artery, and was prescribed a potent statin. Seen in follow-up, she was concerned whether the benefits were worth the risks of intensive statin therapy. After reviewing the strong RCT data on the documented benefits of statin therapy in individuals with symptomatic ASCVD aged 75 and older and comparing it with the risks and negative aspects, she continued on her statin therapy and with careful follow-up has tolerated her therapy well.

What specific information should inform a physician's counseling about benefits and risks of statin therapy in individuals aged 85 and older? Clinicians can explain that RCTs have included elderly adults. Table 1 shows the compelling data for statins in secondary prevention from the Cholesterol Treatment Trialists' meta-analysis as noted above. The Prospective Study of Pravastatin in the Elderly at Risk RCT enrolled individuals in primary and secondary prevention aged 70 to 82. There was a significant reduction in ASCVD risk in the secondary prevention group that a review noted included a mortality benefit.[4] The Study Assessing Goals in the Elderly was a secondary prevention trial that enrolled subjects aged 65 to 86.[5] It contrasted the effects of intensive statin therapy with those of moderate statin therapy on reduction of myocardial ischemia in participants. Both statin regimens were equally effective in the reduction of the frequency and duration of myocardial ischemia. Intensive atorvastatin therapy more effectively improved lipids and reduced all-cause death than moderate pravastatin.

Most experienced clinicians will also want to put in the balance a consideration of harms of any therapy in those 85 and older. Concerns about adding another medication and nonadherence should be considered, and a discussion of metabolic (diabetes mellitus), musculoskeletal (myalgia, myositis, and the very rare rhabdomyolysis), medication interactions, major organ effects (liver and kidney), and memory concerns should ensue.

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