High Cholesterol in Seniors: Use Statins for Primary Prevention?

Kathleen Doheny

May 10, 2023

LONG BEACH, California — For years, clinicians have debated whether prescribing statins to patients older than 75 for the prevention of cardiovascular events is appropriate.

In 2022, the US Preventive Services Task Force concluded that scientific evidence was insufficient to assess the balance between the benefits and harms of the therapy for this older population.

At a session of the American Geriatrics Society (AGS) 2023 Annual Scientific Meeting, experts laid out new preliminary recommendations of the AGS and the National Lipid Association (NLA) on assessing risk and deciding on treatment.

The group concluded that low-density lipoprotein-C (LDL-C) levels are associated with incident arteriosclerotic cardiovascular disease (ASCVD), that the coronary artery calcium (CAC) score can be a valuable measure, and that statins may be reasonable to prescribe, even given the risks that have been linked to statins, such as that for muscle pain. Final recommendations are expected by fall 2023.

Dr Daniel Forman

"This is still a work in progress," Daniel E. Forman, MD, professor of medicine and chair of geriatric cardiology at the University of Pittsburgh, said.

The AGS-NLA panel concluded that for those aged 75 or older without established ASCVD, LDL-C is associated with incident ASCVD, the only recommendation to be given a class I (strong) rating; others were classed as moderate or weak.

Forman reviewed the evidence for lowering LDL-C to decrease ASCVD, citing a 2018 study that concluded, "Reverse causation may contribute to the association of lower TC with higher mortality in nonrandomized studies."

However, research overall shows that as LDL-C levels increase, patients are more likely to experience a heart event.

Forman noted that the utility of equations for assessing 5- or 10-year risk of ASCVD is uncertain. However, he said, traditional risk factors, such as family history and ethnicity, still have value.

Assessing risk "has been enriched in the past few years by the introduction of the coronary artery calcium [CAC] score," he said.

Lower scores predict lower rates of CVD events, Forman said. The AGS-NLA recommends measuring CAC if clinical uncertainty exists about the value of statins.

"It's reasonable to measure CAC and to withhold statins when the CAC is zero," Forman said. "When the CAC score is zero...the risk of having a cardiovascular event is really next to nil. Patients are happy to know they have a CAC of zero."

Likewise, patients appreciate knowing whether their score is high, which would indicate increased risk. He said the CAC score is underused by geriatric physicians.

The group also determined, after reviewing the research, that starting treatment is reasonable for patients with an LDL-C level of 70–189 if they have no life-limiting illness and their life expectancy is over 5 years.

Other preliminary recommendations include the use of statins for those aged 75 and older, irrespective of risk for statin-associated muscle symptoms, type 2 diabetes, or impaired cognition. These associations are often weak, Forman added.

Focusing on Person-Centered Decisions

Ariel Green, MD, MPH, PhD, associate professor of medicine at Johns Hopkins School of Medicine, in Baltimore, said statin therapy "should be individualized" to weigh benefits, noncardiac risks, and other considerations.

Clinicians can incorporate life expectancy into prevention decisions using tools such as ePrognosis, from the University of California, San Francisco, Green said.

If life expectancy is greater than the time to benefit, statin therapy may help. Green cited research that showed that 2.5 years of statin therapy was needed to prevent one major adverse cardiovascular event (MACE) per 100 patients in a population aged 50 to 75. Other data show reductions in MACE for those older than 75, but overall, the data are limited in this population.

The proposed recommendation is to use tools such as life tables that include comorbid conditions and functional status to guide clinical decisions.

"Another aspect of assessing net benefits of statin therapy is to consider competing health risks," Green said.

The group recommends considering using competing risk-adjusted CVD models, though these are not widely used.

The group also recommends integrating screenings for frailty (Clinical Frailty Scale), dementia (Mini-Cog), and functional status (Vulnerable Elders Scale-13) into assessments.

"The presence of these syndromes should prompt elicitation of patient values and preferences related to prevention and medication use," Green said.

Clinicians can use decision aids, but these are not always practical, owing to obstacles such as patients' cognitive problems, Green said.

"Another approach is asking people to prioritize a set of universal health outcomes that apply across health conditions, such as maintaining independence, staying alive, reducing, or eliminating symptoms and focusing on comfort," Green said.

She addressed the evidence about deprescribing statins, with a focus on those with a life expectancy of less than a year. Researchers have found an increase in quality of life and no increases in cardiovascular events or death when statins were deprescribed.

A Welcome Framework

Cory Krueger, MD, an internal medicine and geriatric physician in Cornville, Arizona, who attended the talk, said he welcomed the presentation, in which preliminary recommendations were explained.

"This has been a controversial area in geriatrics," Krueger said. "At least this gave me a framework for discussing this with my patients in a reasonable way."

Forman and Krueger have disclosed no relevant financial relationships. Green receives funding from the National Institute of Aging and Impact Collaboratory.

American Geriatrics Society (AGS) 2023 Annual Scientific Meeting: Presented May 6, 2023

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