Treatment of hypercholesterolaemia in older adults calls for a patient-centred approach

Abstract

Due to an increasing number of older adults with (risk factors for) cardiovascular disease (CVD), the sum of older adults eligible for lipid-lowering drugs will increase. This has risen questions about benefits and harms of lipid-lowering therapy in older adults with a varying number of (cardiovascular) comorbidities and functional status. The heterogeneity in physical and functional health increases with age, leading to a much wider variety in cardiovascular risk and life expectancy than in younger adults. We suggest treatment decisions on hypercholesterolaemia in adults aged ≥75 years should shift from a strictly 10-year cardiovascular risk-driven approach to a patient-centred and lifetime benefit-based approach. With this, estimated 10-year risk of CVD should be placed into the perspective of life expectancy. Moreover, frailty and safety concerns must be taken into account for a risk-benefit discussion between clinician and patient. Based on the Dutch addendum 'Cardiovascular Risk Management in (frail) older adults', our approach offers more detailed information on when not to initiate or deprescribe therapy than standard guidelines. Instead of using traditional risk estimating tools which tend to overestimate risk of CVD in older adults, use a competing risk adjusted, older adults-specific risk score (available at https://u-prevent.com). By filling in a patient's (cardiovascular) health profile (eg, cholesterol, renal function), the tool estimates risk of CVD and models the effect of medication in terms of absolute risk reduction for an individual patient. Using this tool can guide doctors and patients in making shared decisions on initiating, continuing or deprescribing lipid-lowering therapy.

Keywords: cardiovascular disease; frailty; lipid-lowering drugs; older adults.

Figure 1

Cardiovascular risk profiles and potential treatment benefits of lipid-lowering therapy in patients 1 to 3. Estimations of pre-treatment risk of CVD and the potential treatment benefit of LLDs (ie, absolute risk reductions) are based on an older adult-specific, competing risk adjusted risk estimation tool. Estimated life expectancy is based on Holmes et al. Patients 1 and 2 have no pre-existing CVD. Except for hypertension (BP 160/90 mm Hg) and smoking, they have the same cardiovascular risk profile. Patient 1 receives vitamin D, calcium and acetaminophen and is otherwise in good health. Patient 2 receives calcium, vitamin D, a bisphosphonate, hydrochlorothiazide, amlodipine, macrogol and acetaminophen. She is in relatively good health. Both patients are currently not taking any lipid-lowering medication. Patient 3 has experienced a myocardial infarction 6 years ago, has heart failure (NYHA III), mild cognitive impairment, COPD and chronic renal failure (EGFR 30 mL/min/1.73 m²). He makes his way using a walker and uses nine drugs in total on a daily basis. He has been taking simvastatin 40 mg, without any evident side effects, once a day since his myocardial infarction. ARR, absolute risk reduction; BP, blood pressure; COPD, chronic pulmonary disease; CV, cardiovascular; CVD, cardiovascular disease; eGFR, estimated glomerular filtration rate; HDL, high-density lipoprotein; HT, hypertension; LDL-c, low-density lipoprotein cholesterol; LLD, lipid-lowering drug; MI, myocardial infarction; NYHA, New York Heart Association.

Figure 2

Increasing heterogeneity in biological age with increasing chronological age.

Figure 3

Flowchart on treatment of hypercholesterolaemia with lipid-lowering drugs in patients aged ≥75 years. The recommendations are based on the Dutch addendum ‘CVRM in (frail) older adults’. COPD, chronic obstructive pulmonary disease; CVD, cardiovascular disease; CVRM, cardiovascular risk management; LDL-C, low-density lipoprotein cholesterol; TC, total cholesterol.