Effect of Statin Therapy on Mortality in Older Adults Hospitalized With Coronary Artery Disease

A Propensity-Adjusted Analysis

Daniel P. Rothschild, MD; Eric Novak, MS; Michael W. Rich, MD

Disclosures

J Am Geriatr Soc. 2016;64(7):1475-1479. 

In This Article

Abstract and Introduction

Abstract

Objectives: To examine the effect of statins on long-term mortality in older adults hospitalized with coronary artery disease (CAD).

Design: Retrospective analysis.

Setting: University teaching hospital.

Participants: Individuals aged 80 and older (mean aged 85.2, 56% female) hospitalized from January 2006 to December 2010 with acute myocardial infarction (AMI), unstable angina pectoris, or chronic CAD and discharged alive (N = 1,262). Participants were divided into those who did (n = 913) and did not (n = 349) receive a discharge prescription for a statin.

Measurements: All-cause mortality over a median follow-up of 3.1 years.

Results: Participants treated with statins were more likely to be male, to have a primary diagnosis of AMI, to have traditional cardiovascular risk factors, and to receive other standard cardiovascular medications in addition to statins. In unadjusted analysis, statin therapy was associated with lower mortality (hazard ratio (HR) = 0.83, 95% confidence interval (CI) = 0.71–0.96). After adjustment for baseline differences between groups and propensity for receiving statin therapy, the effect of statins on mortality was no longer significant (HR = 0.88, 95% CI = 0.74–1.05). The association between statins and mortality was similar in participants aged 80 to 84 and those aged 85 and older.

Conclusion: In this cohort of older adults hospitalized with CAD, statin therapy had no significant effect on long-term survival after adjustment for between-group differences. These findings, although preliminary, call into question the benefit of statin therapy for secondary prevention in a real-world population of adults aged 80 and older and underscore the need for shared decision-making when prescribing statins in this age group.

Introduction

Although the benefits of statins for primary and secondary prevention of cardiovascular disease (CVD) have been well documented in individuals younger than 75, the value of statins in people aged 75 and older, and particularly those aged 80 and older, is controversial,[1,2] in large part because people these ages have been markedly underrepresented in the large randomized trials of statin therapy.[2] Moreover, older adults enrolled in statin trials tended to be relatively healthy, with few comorbidities and favorable life expectancy, such that there is uncertainty about the generalizability of study findings to the broader older adult population.[3]

In 2013, the American College of Cardiology and American Heart Association published revised guidelines for the management of cholesterol disorders in adults.[4] Incorporated into these guidelines was a new algorithm for estimating 10-year risk of CVD, known as the pooled cohort equations (PCEs).[5] The PCEs promulgate increasing age as the most potent risk factor for CVD. As a result, virtually all men aged 65 and older and all women aged 70 and older in the United States exceed the 7.5% 10-year risk threshold for consideration of statin therapy, yet the guidelines provide no specific recommendations for people aged 75 and older, reflecting the weak evidence base in this age group. Nevertheless, it is noted that the decision to institute statins should be based on an individualized assessment of risks and benefits, with due consideration of individual preferences and goals of care.

More recently, a cost-effectiveness analysis examining the effect of statins on clinical outcomes and costs in individuals aged 75 to 94 was conducted.[6] Although statins were found to reduce cardiovascular events with an acceptable incremental cost-effectiveness ratio, a very low occurrence of significant adverse events, such as myopathy-related disability and cognitive impairment, neutralized the benefits.

Based on these considerations, additional studies are needed to better define the role of statins in older adults with or without prevalent CVD. The purpose of this investigation was to examine the association between statin prescription and survival in individuals aged 80 and older hospitalized with a primary diagnosis of stable coronary artery disease (CAD), unstable angina pectoris, or acute myocardial infarction (AMI).

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