Primary Prevention Statins in Older Adults: Personalized Care for a Heterogeneous Population

Deirdre O'Neill, MD, MSc; Neil J. Stone, MD; Daniel E. Forman, MD

Disclosures

J Am Geriatr Soc. 2020;68(3):467-473. 

In This Article

Abstract and Introduction

Abstract

The 2018 American College of Cardiology/American Heart Association guidelines on the management of cholesterol acknowledge a lack of robust randomized clinical trial data to support routine use of statin therapy for primary prevention in adults older than 75 years. Shared decision making is emphasized because potential recommendations should reflect limitations of the current data, as well as heterogeneity of the older adult population, spanning the robust to the most frail. Although the National Institute on Aging recently funded PRagmatic EValuation of EvENTs And Benefits of Lipid-Lowering in OldEr Adults (PREVENTABLE), a trial to study benefits of statins in very old adults, data are not anticipated for 5 years. Thus interim guidance is essential. Furthermore, even when PREVENTABLE is completed, individual idiosyncrasies among older adults suggest that decisions for each patient will still need to be personalized, relative to their unique clinical situation. In this article, we present three case studies to highlight dynamics that commonly impact choices regarding statins in older adults. Details underlying shared decision making are also described including the evolving application of coronary artery calcium to inform this practice.

Introduction

The recently published American Heart Association/American College of Cardiology (AHA/ACC)/multi-society guideline on the management of cholesterol[1] endorses a tailored approach to care for primary prevention in older adults. These guidelines acknowledge the limitations of the current data, the clinical variability among older adults, and they differentiate recommendations based on each patient's aggregate circumstances. Shared decision making is emphasized with evidence-based therapeutic rationales ranging from aggressive therapy in secondary prevention, to avoiding statins entirely in older adults unlikely to benefit due to frailty or a limited life span.

Older adults are both intrinsically vulnerable to atherosclerotic cardiovascular disease (ASCVD) as well as to iatrogenic effects of statin therapy. Yet data to inform decisions pertaining to primary prevention cholesterol management in older adults are limited. Although the high incidence of ASCVD with age adds to the rationale for the ASCVD-lowering benefits of statins,[2,3] concomitant susceptibilities to frailty, sarcopenia, polypharmacy, and multimorbidity, and to statin-related risks also accumulate with age. Furthermore, a relatively short time to harm from statin therapy may overshadow the relatively longer time to benefit (ie, usually at least 2 years[4]), especially for adults with limited life expectancies. Some studies indicate that statin therapies are useful in older populations, but they tend to focus on younger subsets of older age and exclude candidates who may be excessively burdened by side effects.[5–7]

Given the predominant uncertainties regarding benefits versus risks of primary prevention statin use in the growing population of vulnerable older adults, the National Institutes of Health recently funded a large randomized trial called Pragmatic Evaluation of Events and Benefits of Lipid-Lowering in Older Adults (PREVENTABLE) (RFA-AG-19-020; https://grants.nih.gov/grants/guide/rfa-files/rfa-ag-19-020.html). Although the trial holds considerable promise to clarify goals and process, results are not anticipated for more than 5 years. In the meantime, a critical need persists for strategies to guide statin prescription in older adults. Even when PREVENTABLE's findings are final, the idiosyncrasies of aging in each adult will continue to demand shared decisions because absolute therapeutic directives are rarely advantageous to (or desired by) all older adults at all times.[8] Through the use of case studies, principles of shared decision making are highlighted, with a range of relevant considerations in primary prevention cholesterol management in older adults. Overall, we provide a framework for clinicians faced with the dilemma of clinical equipoise in primary prevention of ASCVD in older adults, allowing them to personalize their decision making.

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