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

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.

Fig. 1

An illustration of how to weigh a “successfully prevented event”, showing two patients with identical cardiovascular risk profiles and their diverging trajectories based on guideline recommendations for statin therapy [, –19]. TC triglycerides, HDL high-density lipoprotein, SBP systolic blood pressure, HTN hypertension, ASCVD atherosclerotic cardiovascular disease, OM diabetes, CV cardiovascular, 1° primary, 2° Secondary, CVD cardiovascular disease, CCS Canadian Cardiovascular Society, NICE-UK The National Institute for Health and Care Excellence United Kingdom, USPSTF United States Preventative Services Task Force, AHA/ACC American Heart Association/American Cardiology Association, ESC/EAS European Society of Cardiology/European Atherosclerosis Society, VA/DoD Veterans Affairs/Department of Defense. ^aIf 10-year risk calculated using the Pooled Cohort Equation. ^bRoyalty-free image titled “person” by Vaibhav Radhakrishnan from the Noun Project. ^cRecommend for patient A as per CCS, NICE-UK, and USPSTF. ^dRecommend for patient Bas per ACC/AHA, AHA/ACC, ESC/EAS and VA/DoD. ^eRecommend for patient Bas er ACC/AHA, AHA/ACC, CCS, ESC/EAS, NICE-UK, and USPSTF (all guidelines except VA/DoD)

Fig. 2

Approach to deprescribing of statins in older adults utilizing the geriatric 5M’s framework [20, 32, 38, 39]. LE life expectancy, ESRD end-stage renal disease. ^aLee and Kim [36]. ^bTjia et al. [45]. ^c Kutner et al. [44]