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Statins for Primary Prevention in Those Aged 70 Years and Older: A Critical Review of Recent Cholesterol Guidelines

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Abstract

The risk of atherosclerotic cardiovascular disease rises with age and remains the leading cause of death in older adults. Evidence for the use of statins for primary prevention in older adults is limited, despite the possibility that this population may derive significant clinical benefit given its increased cardiovascular risk. Until publication of the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the Management of Blood Cholesterol, and the 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease, guidelines for statin prescription in older adults remained unchanged despite new evidence of possible benefit in older adults. In this review, we present key updates in the 2018 and 2019 guidelines and the evidence informing these updates. We compare the discordant recommendations of the seven major North American and European guidelines on cholesterol management released in the past 5 years and highlight gaps in the literature regarding primary prevention of cardiovascular disease in older adults. As most cardiovascular events in older adults are nonfatal, we ask how clinicians should weigh the risks and benefits of continuing a statin for primary prevention in older adults. We also reframe the concept of deprescribing of statins in the older population, using the Geriatrics 5Ms framework: Mind, Mobility, Medications, Multi-complexity, and what Matters Most to older adults. A recent call from the National Institute on Aging for a statin trial focusing on older adults extends from similar concerns.

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References

  1. Singh S, Zieman S, Go AS, Fortmann SP, Wenger NK, Fleg JL, et al. Statins for primary prevention in older adults-moving toward evidence-based decision-making. J Am Geriatr Soc. 2018;66(11):2188–96.

    Article  PubMed  Google Scholar 

  2. Han BH, Sutin D, Williamson JD, Davis BR, Piller LB, Pervin H, et al. Effect of statin treatment vs usual care on primary cardiovascular prevention among older adults: the ALLHAT-LLT randomized clinical trial. JAMA Intern Med. 2017;177(7):955–65.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Mortensen MB, Falk E. Primary prevention with statins in the elderly. J Am Coll Cardiol. 2018;71(1):85–94.

    Article  PubMed  Google Scholar 

  4. Odden MC, Coxson PG, Moran A, Lightwood JM, Goldman L, Bibbins-Domingo K. The impact of the aging population on coronary heart disease in the United States. Am J Med. 2011;124(9):827–833.e5.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Heidenreich PA, Albert NM, Allen LA, Bluemke DA, Butler J, Fonarow GC, et al. Forecasting the impact of heart failure in the United States: a policy statement from the American Heart Association. Circ Heart Fail. 2013;6(3):606–19.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. Thompson W, Pottegard A, Nielsen JB, Haastrup P, Jarbol DE. How common is statin use in the oldest old? Drugs Aging. 2018;35(8):679–86.

    Article  CAS  PubMed  Google Scholar 

  7. Rich MW, Chyun DA, Skolnick AH, Alexander KP, Forman DE, Kitzman DW, et al. Knowledge gaps in cardiovascular care of the older adult population: a scientific statement from the American Heart Association, American College of Cardiology, and American Geriatrics Society. Circulation. 2016;133(21):2103–22.

    Article  PubMed  Google Scholar 

  8. Grundy SM, Stone NJ, Bailey AL, Beam C, Birtcher KK, Blumenthal RS, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2018. https://doi.org/10.1016/j.jacc.2018.11.003 (epub 3 Nov 2018).

    Article  PubMed  Google Scholar 

  9. Orkaby AR, Gaziano JM, Djousse L, Driver JA. Statins for primary prevention of cardiovascular events and mortality in older men. J Am Geriatr Soc. 2017;65(11):2362–8.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Mortensen MB, Nordestgaard B. Comparison of five major guidelines for statin use in primary prevention. Ann Intern Med. 2018;169(1):67–8.

    Article  PubMed  Google Scholar 

  11. Ramos R, Comas-Cufi M, Marti-Lluch R, Ballo E, Ponjoan A, Alves-Cabratosa L, et al. Statins for primary prevention of cardiovascular events and mortality in old and very old adults with and without type 2 diabetes: retrospective cohort study. BMJ. 2018;362:k3359.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Pagidipati NJ, Navar AM, Mulder H, Sniderman AD, Peterson ED, Pencina MJ. Comparison of recommended eligibility for primary prevention statin therapy based on the US Preventive Services Task Force Recommendations vs the ACC/AHA Guidelines. JAMA. 2017;317(15):1563–7.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Ridker PM, Lonn E, Paynter NP, Glynn R, Yusuf S. Primary prevention with statin therapy in the elderly: new meta-analyses from the contemporary JUPITER and HOPE-3 randomized trials. Circulation. 2017;135(20):1979–81.

    PubMed  Google Scholar 

  14. Arnett DK, Blumenthal RS, Albert MA, Buroker AB, Goldberger ZD, Hahn EJ, et al. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease. Circulation. 2019. https://doi.org/10.1161/cir.0000000000000678 (epub 17 Mar 2019).

    Article  PubMed  Google Scholar 

  15. United States Department of Veterans Affairs and United States Department of Defense. VA/DoD clinical practice guideline for the management of dyslipidemia for cardiovascular risk reduction. Guidelines. 2014. Available at: http://www.healthquality.va.gov/guidelines/CD/lipids/VADoDDyslipidemiaCPG.pdf. Accessed 9 Jan 2019.

  16. National Institute for Health and Clinical Excellence. Lipid modification: cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease. Clinical Guideline CG181. London: National Clinical Guideline Centre; 2014.

  17. Anderson TJ, Gregoire J, Pearson GJ, Barry AR, Couture P, Dawes M, et al. 2016 Canadian Cardiovascular Society Guidelines for the management of dyslipidemia for the prevention of cardiovascular disease in the adult. Can J Cardiol. 2016;32(11):1263–82.

    Article  PubMed  Google Scholar 

  18. Bibbins-Domingo K, Grossman DC, Curry SJ, Davidson KW, Epling JW Jr, Garcia FA, et al. Statin use for the primary prevention of cardiovascular disease in adults: US preventive services task force recommendation statement. JAMA. 2016;316(19):1997–2007.

    Article  PubMed  Google Scholar 

  19. Piepoli MF, Hoes AW, Agewall S, Albus C, Brotons C, Catapano AL et al. 2016 European guidelines on cardiovascular disease prevention in clinical practice. The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts. Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation. G Ital Cardiol (Rome). 2017;18(7):547–612.

  20. Bennet CS, Dahagam CR, Virani SS, Martin SS, Blumenthal RS, Michos ED, et al. Lipid management guidelines from the departments of veteran affairs and defense: a critique. Am J Med. 2016;129(9):906–12.

    Article  PubMed  Google Scholar 

  21. Tinetti M, Huang A. The geriatrics 5M’s: a new way of communicating what we do. J Am Geriatr Soc. 2017;65(9):2115.

    Article  PubMed  Google Scholar 

  22. Hippisley-Cox J, Coupland C, Vinogradova Y, Robson J, Minhas R, Sheikh A, et al. Predicting cardiovascular risk in England and Wales: prospective derivation and validation of QRISK2. BMJ. 2008;336(7659):1475–82.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Downs JR, O’Malley PG. Management of dyslipidemia for cardiovascular disease risk reduction: synopsis of the 2014 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guideline. Ann Intern Med. 2015;163(4):291–7.

  24. Navar AM, Peterson ED. Evolving approaches for statins in primary prevention: progress, but questions remain. JAMA. 2016;316(19):1981–3.

    Article  PubMed  Google Scholar 

  25. Stone NJ, Intwala S, Katz D. Response by Neil J. Stone, Sunny Intwala, and Dan Katz. J Am Geriatr Soc. 2014;62(5):947–8.

  26. Savarese G, Gotto AM Jr, Paolillo S, D’Amore C, Losco T, Musella F, et al. Benefits of statins in elderly subjects without established cardiovascular disease: a meta-analysis. J Am Coll Cardiol. 2013;62(22):2090–9.

    Article  CAS  PubMed  Google Scholar 

  27. Chou R, Dana T, Blazina I, Daeges M, Jeanne TL. Statins for prevention of cardiovascular disease in adults: evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2016;316(19):2008–24.

    Article  PubMed  Google Scholar 

  28. Stone NJ, Robinson JG, Lichtenstein AH, Bairey Merz CN, Blum CB, Eckel RH et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63(25 Pt B):2889–934.

  29. Gurwitz JH, Go AS, Fortmann SP. Statins for primary prevention in older adults: uncertainty and the need for more evidence. JAMA. 2016;316(19):1971–2.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  30. Yusuf S, Bosch J, Dagenais G, Zhu J, Xavier D, Liu L, et al. Cholesterol lowering in intermediate-risk persons without cardiovascular disease. N Engl J Med. 2016;374(21):2021–31.

    Article  CAS  PubMed  Google Scholar 

  31. Glynn RJ, Koenig W, Nordestgaard BG, Shepherd J, Ridker PM. Rosuvastatin for primary prevention in older persons with elevated C-reactive protein and low to average low-density lipoprotein cholesterol levels: exploratory analysis of a randomized trial. Ann Intern Med. 2010;152(8):488–96, w174.

  32. Kim K, Lee CJ, Shim CY, et al. Statin and clinical outcomes of primary prevention in individuals aged > 75 years: the SCOPE-75 study. Atherosclerosis. 2019;284:31–6.

    Article  CAS  PubMed  Google Scholar 

  33. Huesch MD. Association of baseline statin use among older adults without clinical cardiovascular disease in the SPRINT TRial. JAMA Intern Med. 2018;178(4):560–1.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Bezin J, Moore N, Mansiaux Y, Steg PG, Pariente A. Real-life benefits of statins for cardiovascular prevention in elderly subjects: a population-based cohort study. Am J Med. 2019. https://doi.org/10.1016/j.amjmed.2018.12.032 (epub 18 Jan 2019).

    Article  PubMed  Google Scholar 

  35. Cholesterol Treatment Trialists’ Collaboration. Efficacy and safety of statin therapy in older people: a meta-analysis of individual participant data from 28 randomised controlled trials. Lancet. 2019;393(10170):407–15.

    Article  Google Scholar 

  36. Lee SJ, Kim CM. Individualizing prevention for older adults. J Am Geriatr Soc. 2018;66(2):229–34.

    Article  PubMed  Google Scholar 

  37. Barter PJ, Waters DD. Variations in time to benefit among clinical trials of cholesterol-lowering drugs. J Clin Lipidol. 2018;12(4):857–62.

  38. Ruscica M, Macchi C, Pavanello C, et al. Appropriateness of statin prescription in the elderly. Eur J Intern Med. 2018;50:33–40.

    Article  CAS  PubMed  Google Scholar 

  39. Orkaby AR, Rich MW, Sun R, Lux E, Wei LJ, Kim DH. Pravastatin for primary prevention in older adults: restricted mean survival time analysis. J Am Geriatr Soc. 2018;66(10):1987–91.

    Article  PubMed  Google Scholar 

  40. Gulliford M, Ravindrarajah R, Hamada S, Jackson S, Charlton J. Inception and deprescribing of statins in people aged over 80 years: cohort study. Age Ageing. 2017;46(6):1001–5.

    Article  PubMed  PubMed Central  Google Scholar 

  41. Rich MW. Aggressive lipid management in very elderly adults: less is more. J Am Geriatr Soc. 2014;62(5):945–7.

    Article  PubMed  Google Scholar 

  42. Stone NJ, Intwala S, Katz D. Statins in very elderly adults (debate). J Am Geriatr Soc. 2014;62(5):943–5.

    Article  PubMed  Google Scholar 

  43. Holmes HM, Todd A. Evidence-based deprescribing of statins in patients with advanced illness. JAMA Intern Med. 2015;175(5):701–2.

    Article  PubMed  PubMed Central  Google Scholar 

  44. Kutner JS, Blatchford PJ, Taylor DH Jr, Ritchie CS, Bull JH, Fairclough DL, et al. Safety and benefit of discontinuing statin therapy in the setting of advanced, life-limiting illness: a randomized clinical trial. JAMA Intern Med. 2015;175(5):691–700.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Tjia J, Cutrona SL, Peterson D, Reed G, Andrade SE, Mitchell SL. Statin discontinuation in nursing home residents with advanced dementia. J Am Geriatr Soc. 2014;62(11):2095–101.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Garfinkel D, Ilhan B, Bahat G. Routine deprescribing of chronic medications to combat polypharmacy. Ther Adv Drug Saf. 2015;6(6):212–33.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  47. Qi K, Reeve E, Hilmer SN, Pearson SA, Matthews S, Gnjidic D. Older peoples’ attitudes regarding polypharmacy, statin use and willingness to have statins deprescribed in Australia. Int J Clin Pharm. 2015;37(5):949–57.

    Article  PubMed  Google Scholar 

  48. Kuchel GA. Frailty and resilience as outcome measures in clinical trials and geriatric care: are we getting any closer? J Am Geriatr Soc. 2018;66(8):1451–4.

    Article  PubMed  PubMed Central  Google Scholar 

  49. Kim DH, Glynn RJ, Avorn J, Lipsitz LA, Rockwood K, Pawar A et al. Validation of a claims-based frailty index against physical performance and adverse health outcomes in the health and retirement study. J Gerontol A Biol Sci Med Sci. 2018.

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Acknowledgements

The authors would like to thank Dr. Shoshana Streiter for her assistance with copy editing the manuscript.

Author information

Authors and Affiliations

  1. New England Geriatric Research, Education, and Clinical Center (GRECC), VA Boston Healthcare System, Boston, MA, USA

    Chelsea E. Hawley & Ariela R. Orkaby

  2. Pharmacy Department, VA Boston Healthcare System, Boston, MA, USA

    Chelsea E. Hawley & John Roefaro

  3. Section of Geriatric Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA

    Daniel E. Forman

  4. Geriatric Research, Education, and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA

    Daniel E. Forman

  5. Division of Aging, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA

    Ariela R. Orkaby

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  1. Chelsea E. Hawley
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Corresponding author

Correspondence to Chelsea E. Hawley.

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Funding

Dr. Forman is supported by NIA Grants R01-AG060499-01, R01-AG051376, and P30-AG024827. Dr. Orkaby is supported by a Veterans Affairs Clinical Science Research and Development CDA-2 award (IK2-CX001800), a career development award from the Boston Claude D. Pepper Older Americans Independence Center, and NIA Grant P30-AG031679, and NIA GEMSSTAR award R03-AG060169. The funders played no role in the publication of the manuscript.

Conflict of interest

Chelsea E. Hawley, John Roefaro, Daniel E. Forman, and Ariela R. Orkaby have no conflicts of interest to declare that are directly relevant to the content of this article.

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Hawley, C.E., Roefaro, J., Forman, D.E. et al. Statins for Primary Prevention in Those Aged 70 Years and Older: A Critical Review of Recent Cholesterol Guidelines. Drugs Aging 36, 687–699 (2019). https://doi.org/10.1007/s40266-019-00673-w

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