COMMENTARY

Statins in the Elderly: Evidence-Based or Not?

Tom G. Bartol, NP

Disclosures

March 12, 2018

Statins for Primary Prevention of Cardiovascular Disease

Recently, secondary data from the SPRINT blood pressure trial evaluated statin use in elderly trial subjects without diabetes.[1] Because the SPRINT trial didn't randomize statin use, statistical inverse probability weighted (IPW) methods were used to account for nonrandom statin use. The primary endpoint was a composite of myocardial infarction, other acute coronary syndrome, stroke, heart failure, or cardiovascular-related death.

Of 3054 patients in the study (mean age, 77 years), 44.2% were taking statins at baseline. The primary event rate was 8.1% without a statin and 6.3% with a statin, an absolute risk reduction with a statin of 1.8% (P = .13). The average time to an event without a statin was 753.8 days versus 669.2 days when on a statin, a nonsignificant difference of 84.6 days.

The researchers concluded from these findings that statins would offer no benefit in the primary prevention of cardiovascular disease (CVD) in adults over age 65.

Viewpoint

Clinical guidelines and research can lead us to decisions about treatment for patients, believing that these decisions are in the patients' best interest. Statins certainly have been shown time and again to reduce the incidence of cardiovascular events, but there is a bigger picture—a broader perspective—that often gets bumped aside in our focus on evidence-based medicine.[2]

Although the evidence points to a reduction in cardiovascular events when statins are used for primary prevention, the absolute risk reduction is often small and the studies have not shown a reduction in all-cause mortality.[3] Most data on statins in the elderly is from a subgroup analysis of a small number of people over age 65, leaving little that we can definitively conclude about statin use.[4] Some studies even show a correlation of higher cholesterol levels at baseline in people over age 65 with lower all-cause and noncardiovascular mortality.[5]

The Choosing Wisely campaign has issued a statement on statins in those over age 75, saying there is "no clear evidence that high cholesterol leads to heart disease or death" in this population and that some studies show that people with the lowest levels of cholesterol have the highest risk of death.[6]

It's time to remember that clinical guidelines are just that—guidelines, not mandates. Rather than treating a person solely on the basis of a lab test or a risk calculation, we must talk to the patients, share information, and encourage them to make decisions that reflect their goals, values, and desires. Many older patients seek quality of life rather than quantity of life. Simply treating them according to a guideline or a risk calculation does not take into account what the patients may want; we can easily lead patients to believe that a medication has more benefit for them than it may actually provide. We must not get bogged down in evidence-based decisions when, in this case, there is little hard evidence.

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