Statin Use Over 65 Years of Age and All-Cause Mortality

A 10-Year Follow-Up of 19 518 People

Sophia Eilat-Tsanani, MD; Elad Mor, MD; Yochai Schonmann, MD, MSc

Disclosures

J Am Geriatr Soc. 2019;67(10):2038-2044. 

In This Article

Abstract and Introduction

Abstract

Objectives: As life expectancy continues to rise, the burden of cardiovascular disease among older people is expected to increase, making cardiovascular prevention in older people an issue of growing interest and public health importance. We aimed to explore the long-term effects of adherence to statins on mortality and cardiovascular morbidity among older adults.

Design: A historical population-based cohort study using routinely collected data.

Setting: Clalit Health Services Northern District.

Participants: We followed members of Clalit Health Services aged 65 years or older who were eligible for primary cardiovascular prevention for a period of 10 years.

Measurements: We fitted Cox regression models to assess the association between the adherence to statin therapy and all-cause mortality and cardiovascular morbidity, adjusting for cardiovascular risk factors and associated morbidity as time-updated variables.

Results: The analysis included 19 518 older adults followed during 10 years (median = 9.7 y). All-cause mortality rates were 34% lower among those who had adhered to statin treatment, compared with those who had not (hazard ratio [HR] = .66; 95% confidence interval [CI] = .56-.79). Adherence to statins was also associated with fewer atherosclerotic cardiovascular disease events (HR = .80; 95% CI = .71-.81). The benefit of statin use did not diminish among beyond age 75 and was evident for both women and men.

Conclusion: Adherence to statins may be associated with reduced mortality and cardiovascular morbidity among older adults, regardless of age and sex.

Introduction

Atherosclerotic cardiovascular diseases (ASCVDs) are the leading cause of disability and mortality worldwide. Cardiovascular risk increases with age, and more than 60% of attributed deaths occur after 75 years of age.[1] As life expectancy continues to rise, the burden of cardiovascular diseases among older people is expected to increase,[2] making cardiovascular prevention in older people an issue of growing interest and public health importance.[3] Cholesterol-lowering medications, a cornerstone of primary and secondary cardiovascular prevention, are endorsed by all major international guidelines.[4–7] Statins, the most commonly used of these medications, are safe and effective in lowering low-density lipoprotein cholesterol (LDL-C) levels, preventing cardiovascular events, and reducing mortality.[8,9] Some evidence supports the use of statins for secondary prevention among frail older patients,[10] as well as for the tolerability of statins among the oldest old.[11] However, people beyond the age of 75 are not routinely represented in randomized controlled trials, and there is little evidence to support the efficacy of statins in primary prevention in that age group.[8,12]

In real life, physicians frequently prescribe statins to older patients despite the paucity of evidence, and the use of statins among this age group is increasing.[13–15] One-third of Danish adults aged 56 to 85 years use statins,[15] and in the United States more than 60% of older people with hyperlipidemia take statins for primary prevention.[14] Adherence to statin treatment is consistently associated with lower levels of LDL-C and with fewer hospitalizations and ASCVD events.[16] However, less than 50% of those older than age 65 adhere to statin therapy during the first year, and adherence decreases with older age and in the following years.[17] Importantly, adherence to preventive therapy may also be a marker for engaging in other healthy behaviors, such as better diet or less smoking ("healthy adherer effect").[18]

Recent studies attempted to assess the efficacy of statins for primary prevention among older people with conflicting results and with various methodological limitations. The external validity of post hoc secondary analyses of trial data is limited;[8,19,20] observational analyses relied on self-report;[21] included only new users of statins (and would, therefore, be less applicable to the growing population of older prevalent statin users);[22,23] or did not account for actual statin use or adherence beyond the baseline accrual period.[21,23] An ongoing randomized control trial, Statin Therapy for Reducing Events in the Elderly (STAREE) was launched in 2015, but results have not been published to date.[24]

Current guidelines reflect this knowledge gap and do not make clear recommendations regarding older people,[4–7] highlighting a growing need for data to support treatment decisions among older people. We aimed to explore the long-term effect of real-life statin use for primary prevention and adherence on mortality and cardiac morbidity among older people using data from a large not-for-profit health organization.

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