Lipid-modifying therapy in the elderly

Abstract

Cardiovascular disease (CVD) mortality and morbidity increases with increasing age, largely as a result of increased lifetime exposure as well as increased prevalence of CVD risk factors. Hospitalization for CVD increases by a factor of over 18× for those aged 85+ years versus those aged <30 years. In spite of this, life expectancy continues to increase, and in Australia for people reaching the age of 65 years, it is now 84 years in men and 87 years in women. The number of people for whom lipid management is potentially indicated therefore increases with aging. This is especially the case for secondary prevention and for people aged 65-75 years for whom there is also evidence of benefit from primary prevention. Many people in this age group are not treated with lipid-lowering drugs, however. Even those with CVD may be suboptimally treated, with one study showing treatment rates to fall from ~60% in those aged <50 years to <15% for those aged 85+ years. Treatment of the most elderly patient groups remains controversial partly from the lack of randomized trial intervention data and partly from the potential for adverse effects of lipid therapy. There are many complex issues involved in the decision to introduce effective lipid-lowering therapy and, unfortunately, in many instances there is not adequate data to make evidence-based decisions regarding management. This review summarizes the current state of knowledge of the management of lipid disorders in the elderly and proposes guidelines for management.

Keywords: elderly; lipid management; statins.

Figure 1

Mean odds ratios for treatment with lipid therapy according to age.

Figure 2

Hospitalizations for CVD per 100,000 people in the Australian population according to age and sex.

Figure 3

Cardiovascular risk according to risk factors and total cholesterol levels in the Dubbo study. Notes: Reference group: not taking antihypertensive medication; systolic pressure 140 mmHg; non-smoking; high-density lipoprotein level 1.10 mmol/L; no diabetes.

Figure 4

Vascular mortality according to age and total cholesterol level in the Prospective Studies Collaboration.

Figure 5

Proportion of private lipoprotein tests in Queensland in 1 year according to age.

Figure 6

Meta-analysis of patients with cardiovascular disease aged >60 years according to statin versus placebo treatment. Note: Reproduced from Roberts CG, Guallar E, Rodriguez A. Efficacy and safety of statin monotherapy in older adults: a meta-analysis. J Gerontol A Biol Sci Med Sci. 2007;62:879–887, by permission of Oxford University Press. Abbreviations: LIPID, the Long-Term Intervention with Pravastatin in Ischaemic Disease (LIPID) Study Group; CARDS, Collaborative Atorvastatin Diabetes Study; HPS, Heart Protection Study; SCAT, Simvastatin/Enalapril Coronary Atherosclerosis Trial; PROSPER, Pravastatin in elderly individuals at risk of vascular disease; 4S, Scandinavian Simvastatin Survival Study; ACAPS, Asymptomatic Carotid Artery Progression Study; CARE, the Cholesterol and Recurrent Events trial; ASCOT-LLA, Anglo-Scandinavian Cardiac Outcomes Trial–Lipid Lowering Arm (ASCOT-LLA); PLAC-I, Pravastatin Limitation of Atherosclerosis in the Coronary arteries I; PLAC-II, Pravastatin Limitation of Atherosclerosis in the Coronary arteries II; AFCAPS/TexCAPS, Air Force/Texas Coronary Atherosclerosis Prevention Study.

Figure 7

Predicted 5-year benefits of LDL cholesterol reductions with statin treatment at different levels of risk in Cholesterol Treatment Trialists’ Collaboration meta-analysis.

Figure 8

Major vascular event rate with statin treatment according to age in Cholesterol Treatment Trialists’ Collaboration meta-analysis.

Figure 9

Reduction in coronary death or hospitalization for myocardial infarction with pravastatin versus placebo treatment. Notes: Numbers of patients included in the study are provided according to year since randomization for patients treated with either placebo (upper line of X axis) or pravastatin (lower line of X axis). © 2013 Lloyd SM, Stott DJ, de Craen AJ, et al. Long-term effects of statin treatment in elderly people: extended follow-up of the PROspective Study of Pravastatin in the Elderly at Risk (PROSPER). PLoS One. 2013;8:e72642. Abbreviation: MI, myocardial infarction.

Figure 10

Mortality reduction in cardiovascular disease patients with statin treatment according to age. Note: Black bars: no statin treatment; white bars: statin treatment.

Figure 11

Benefits of simvastatin versus placebo treatment in Scandinavian Simvastatin Survival Study. Note: The Y axis of both graphs refers to proportion alive where 1.00=100%.