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

Discussion

Patients aged 80 and older discharged with a primary diagnosis of CAD, unstable angina pectoris, or AMI who were prescribed statins at the time of discharge had long-term survival similar to that of those who were not prescribed statins, after adjustment for baseline differences between groups and propensity to receive statin therapy. These findings question the routine use of statins, even for secondary prevention, in an unselected population of high-risk individuals aged 80 and older. The findings also support current guideline recommendations to consider multiple factors, including comorbidities, life expectancy, and individuals' preferences in deciding whether to prescribe statins in older adults.[4]

In contrast to prior reports,[10] statin recipients appear to have been sicker than those who did not receive statins (more likely to have AMI as the index diagnosis and more likely to have hypertension, diabetes mellitus, and peripheral arterial disease). The mean age of the statin group was also identical to that of the nonstatin group. Conversely, patients in the statin group were more likely to receive all other cardiovascular drugs. Thus, it appears that the statin group was treated more aggressively, which may account for the fact that mortality was similar in the two groups despite an apparently higher risk profile in the statin group.

There was no interaction between age, statin use, and outcomes. It was anticipated that individuals aged 80 to 84 might benefit more from statins than those aged 85 and older because of their longer remaining life expectancy, but the adjusted HR for mortality in statin users versus nonusers was consistent across the age spectrum of subjects included in this analysis.

Earlier studies, including the Prospective Study of Pravastatin in the Elderly at Risk (PROSPER) and the Justification for the Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin (JUPITER), suggested that statins may be beneficial in selected high-risk older adults,[11–13] but the mean age of PROSPER participants was 75.3 years,[11] and in the JUPITER subgroup analysis of participants aged 70 and older the mean age was 74.[12] In addition, both studies excluded individuals with complex comorbidities. In contrast, the mean age in the present study was 85, and all individuals discharged alive were included in the analysis. Thus, the findings are likely to be more representative of real-world people aged 80 and older.

This study has several limitations. Data were obtained retrospectively from a single academic center, and data were not available for a multitude of unmeasured confounding factors, including several common comorbidities, such as chronic lung disease and cancer, that may have influenced the decision to prescribe statins. Because people with more-complex comorbidity may be less likely to receive statins and have higher mortality, lack of inclusion of these comorbidities might be expected to favor the statin group. Information was not available on potentially relevant baseline factors, such as left ventricular ejection fraction or performance of revascularization during the index admission, or on medication use during follow-up, and although some studies have found a strong correlation between discharge medications and follow-up medications, up to 50% of statin users discontinue treatment within 2 years of initiation.[14,15] The sample size was modest, and the possibility of a clinically meaningful mortality benefit from statins cannot be excluded. Nevertheless, even a small adverse effect on disability-adjusted quality of life would neutralize any beneficial effects of statins in this age group.[6]

In summary, the present analysis failed to show a survival benefit attributable to statins in individuals aged 80 and older hospitalized with acute or chronic manifestations of CAD. These findings call into question the routine use of statins in this population, support the conservative recommendations of current guidelines, and underscore the need for well-designed prospective studies to better define the role of statins in primary and secondary prevention of CVD in older adults. Until these studies have been completed, providers and patients should engage in shared-decision making that incorporates discussion of the potential risks and benefits of statin therapy while considering the individual's values and preferences.

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