Should a 75-year-old patient with hypercholesterolemia (high cholesterol) be initiated on lipid-lowering medication?

From the Guidelines

The 75-year-old patient with high cholesterol should be started on a moderate-intensity statin, such as atorvastatin 10-20 mg daily or rosuvastatin 5-10 mg daily, after individualizing their treatment based on their overall cardiovascular risk profile, potential for ASCVD risk-reduction benefits, adverse effects, drug-drug interactions, and patient preferences. This recommendation is based on the 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults, which suggests that moderate-intensity statins are recommended for patients >75 y of age 1.

When considering statin therapy for this patient, several factors should be taken into account, including:

• Their overall cardiovascular risk profile, including the presence of additional risk factors such as hypertension, diabetes, smoking history, or previous cardiovascular events
• The potential for ASCVD risk-reduction benefits, as statins have been shown to reduce cardiovascular events, including coronary heart disease death, recurrent MI, cerebrovascular events, coronary revascularization, and all-cause mortality 1
• Adverse effects, such as muscle pain, and periodic liver function tests, which are important to monitor, especially in older adults who may be more susceptible to adverse effects
• Drug-drug interactions, which should be evaluated in the context of the patient's existing medications
• Patient preferences, which should be considered when individualizing treatment

Lifestyle modifications, including a heart-healthy diet, regular physical activity, smoking cessation, and weight management, should accompany any medication regimen. Statins work by inhibiting HMG-CoA reductase, reducing cholesterol synthesis in the liver and increasing LDL receptor activity, which lowers circulating LDL cholesterol levels 1. Regular monitoring for side effects and periodic liver function tests are important to ensure the safe use of statins in this patient population.

From the FDA Drug Label

Adults at High Risk of Coronary Heart Disease Events In a randomized, double-blind, placebo-controlled, multi-centered study [the Scandinavian Simvastatin Survival Study (Study 4S)], the effect of therapy with simvastatin on total mortality was assessed in 4,444 adult patients with CHD (history of angina and/or a previous myocardial infarction) and baseline total cholesterol (total-C) between 212 and 309 mg/dL who were on a lipid-lowering diet. Simvastatin resulted in similar decreases in relative risk for total mortality, CHD mortality, and major coronary events in geriatric patients (≥65 years) compared with younger adults.

Key Points:

• The study included patients with high cholesterol and a history of coronary heart disease.
• Simvastatin significantly reduced the risk of mortality and major coronary events.
• The study found similar risk reductions in geriatric patients (≥65 years) compared to younger adults.

A 75-year-old patient with high cholesterol should be considered for medication, as the study suggests that simvastatin can reduce the risk of mortality and major coronary events in patients with high cholesterol, including those over 65 years old 2.

From the Research

Medication for High Cholesterol in a 75-Year-Old

• The provided study 3 discusses the efficacy and safety of ezetimibe coadministered with atorvastatin or simvastatin in patients with homozygous familial hypercholesterolemia.
• The study found that ezetimibe plus statin-40/80 significantly reduced LDL-C levels compared with statin-80, with a mean percentage change of -20.7% versus -6.7% (P=0.007) 3.
• However, this study does not directly address the question of whether a 75-year-old with high cholesterol should be started on medication, as it focuses on a specific population with homozygous familial hypercholesterolemia.
• The study's findings on the safety and efficacy of ezetimibe coadministered with atorvastatin or simvastatin may not be directly applicable to a 75-year-old with high cholesterol, as the study population had a specific diagnosis of homozygous familial hypercholesterolemia 3.

Considerations for Older Adults

• There are no research papers provided that directly assist in answering the question of whether a 75-year-old with high cholesterol should be started on medication.
• In general, treatment decisions for high cholesterol in older adults would depend on various factors, including the individual's overall health, medical history, and cardiovascular risk factors.