Managing Hypercholesterolemia in Adults Older Than 75 years Without a History of Atherosclerotic Cardiovascular Disease: An Expert Clinical Consensus From the National Lipid Association and the American Geriatrics Society

Abstract

The risk of atherosclerotic cardiovascular disease increases with advancing age. Elevated LDL-cholesterol and non-HDL-cholesterol levels remain predictive of incident atherosclerotic cardiovascular events among individuals older than 75 years. Risk prediction among older individuals is less certain because most current risk calculators lack specificity in those older than 75 years and do not adjust for co-morbidities, functional status, frailty, and cognition which significantly impact prognosis in this age group. Data on the benefits and risks of lowering LDL-cholesterol with statins in older patients without atherosclerotic cardiovascular disease are also limited since most primary prevention trials have included mostly younger patients. Available data suggest that statin therapy in older primary prevention patients may reduce atherosclerotic cardiovascular events and that benefits from lipid-lowering with statins outweigh potential risks such as statin-associated muscle symptoms and incident Type 2 diabetes mellitus. While some evidence suggests the possibility that statins may be associated with incident cognitive impairment in older adults, a preponderance of literature indicates neutral or even protective statin-related cognitive effects. Shared decision-making which is recommended for all patients when considering statin therapy is particularly important in older patients. Randomized clinical trial data evaluating the use of non-statin lipid-lowering therapy in older patients are sparse. Deprescribing of lipid-lowering agents may be appropriate for select patients older than 75 years with life-limiting diseases. Finally, a patient-centered approach should be taken when considering primary prevention strategies for older adults.

Keywords: hypercholesterolemia; older adult; primary prevention.

FIGURE 1

2019 Updated ACC/AHA Clinical Practice Guideline Recommendation Classification System (table modified from the 2019 ACC/AHA Clinical Practice Guideline Recommendation Classification System).,

FIGURE 2

Number needed to treat for primary prevention of MI and ASCVD by age. Data from the Prospective Copenhagen General Study. The graph shows the number needed to treat (NNT) to prevent 1 event over 5 years for 1 mmol/L (~39 mg/dL) lower LDL‐C by age group for the endpoints myocardial infarction and ASCVD. NNT declines with advancing age consistent with greater benefit in the older compared to younger age groups.

FIGURE 3

Managing hypercholesterolemia in primary prevention patients older than 75 years, with LDL‐C 70–189 mg/dL. Colors correspond to class of recommendation in Figure 1. ASCVD, atherosclerotic cardiovascular disease; CAC, coronary artery calcium; LDL‐C, low density lipoprotein cholesterol.