Statins for primary prevention provide similar protection among older vs. younger adults
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Key takeaways:
- Patients aged 70 years or older derive similar LDL lowering with statin therapy vs. younger patients.
- The magnitude of risk reduction for first CV events was also similar between the two groups.
Older individuals appeared to derive similar magnitude of LDL lowering and CV risk reduction from statin therapy initiation vs. younger patients, according to data from a large Danish study.
“Use of lipid-lowering therapy to reduce LDL cholesterol constitutes the main pharmacologic intervention strategy for both primary and secondary prevention of atherosclerotic CVD. Evidence from clinical trials of treatments lowering LDL cholesterol has shown that the relative risk of major vascular events is reduced by about one-fifth per each 1 mmol/L lowering of LDL cholesterol,” Niklas Worm Andersson, MD, of the department of epidemiology research at the Statens Serum Institut in Copenhagen, Denmark, and colleagues wrote. “For older individuals, however, data to support the benefit of LDL cholesterol-lowering treatment for cardiovascular risk reduction are sparse because elderly people are generally underrepresented in the individual trials. This lack of evidence is particularly pronounced for primary prevention.”
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To evaluate the effect of statins for primary prevention in older individuals, Andersson and colleagues gathered crosslinked data from different Danish national health care and administrative registries. Their analysis included 65,190 adults aged at least 50 years who initiated statin therapy from January 2008 to October 2017, with no history of ASCVD.
The results were published in the Journal of the American College of Cardiology.
Statins for primary prevention in older adults without ASCVD
Overall, 16,035 participants were aged at least 70 years (mean age, 75.4 years; 57.5% women) and 49,155 were younger than 70 years (mean age, 60.2 years; 53% women).
The primary outcome was a composite of hospitalization for major vascular events, including ACS, nonhemorrhagic stroke and coronary revascularization.
After 1 year of statin treatment, the median reduction in LDL cholesterol (1.7 mmol/L) was the same between both age groups.
Among individuals aged at least 70 years, every 1 mmol/L reduction in LDL cholesterol was associated with a 23% lower risk for the primary endpoint (HR = 0.76; 95% CI, 0.71-0.8).
The magnitude of CV benefit was similar among patients younger than 70 years (HR = 0.76; 95% CI, 0.71-0.8; P value for difference between the groups = .79).
Andersson and colleagues did not observe any significant difference between older and younger individuals in risk for the primary outcomes across any subgroup analyses.
Moreover, absolute change in 5-year risk for individuals with an LDL cholesterol reduction of 1.7 mmol/L or more compared with those with no reduction was not significantly larger among older compared with younger patients.
“Our results, based on a substantial sample size representative of a contemporary general population, may contribute to informing future guideline recommendations and clinician-patient discussion on the clinical benefit observed from lowering LDL cholesterol among older individuals for primary prevention of cardiovascular disease during routine clinical care,” the researchers wrote. “Of note, any potential clinical benefit should be balanced against the potential of harm, and this study did not assess the safety of lipid-lowering treatment according to age. Because pharmacokinetics and pharmacodynamics alter with older age, and because of increasing comorbidity and comedication burdens, advances in such research directions could also help steer clinical decision-making.”
Risk-to-benefit balance ‘crucial in primary prevention’
In a related editorial, Safi U. Khan, MD, MS, a cardiovascular disease fellow at Houston Methodist and DeBakey Heart and Vascular Center, discussed the importance of balancing potential risk with the benefits of statin for primary prevention as well as areas for future research.
“Balancing risk and benefit is particularly crucial in primary prevention, and more so in the older population, where conditions such as statin-induced myalgias can have a disproportionate impact,” Khan wrote. “Ultimately, physicians must have comprehensive discussions with patients about the potential harms and benefits of LDL-C reduction therapy to guide informed personalized treatment choices.
“The study by Andersson et al contributes valuable insights regarding the effects of LDL-C-lowering therapy, especially as the burgeoning aging population faces escalating burden of ASCVD,” he wrote. “As we move forward, the research agenda should focus on corroborating these findings and addressing the safety of lipid-lowering treatments in older individuals. Hopefully, the ongoing randomized controlled trial STAREE ... which is comparing statin with placebo in more than 18,000 patients aged 70 years without ASCVD, will yield further insights.”
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