Should I order a statin for an 88-year-old male with a history of cerebrovascular accident (CVA), coronary artery disease (CAD), atrial fibrillation, left ventricular thrombus, congestive heart failure (CHF), and hypertension?

From the Guidelines

You should consider ordering a statin for this 88-year-old male patient with multiple cardiovascular risk factors, as the potential benefits of statin therapy likely outweigh the risks in secondary prevention, despite his advanced age. The patient's history of cerebrovascular accident (CVA), coronary artery disease (CAD), atrial fibrillation, left ventricular thrombus, congestive heart failure (CHF), and hypertension places him at very high risk for recurrent cardiovascular events. According to the 2019 guidelines on the management of blood cholesterol, for patients older than 75 years of age with clinical ASCVD, it is reasonable to initiate moderate- or high-intensity statin therapy after evaluation of the potential for ASCVD risk reduction, adverse effects, and drug–drug interactions, as well as patient frailty and patient preferences 1.

Given his extensive cardiovascular history, high-intensity statins like atorvastatin 40-80mg daily or rosuvastatin 20-40mg daily could be considered, but if concerns exist about tolerability in this elderly patient, moderate-intensity options like atorvastatin 10-20mg daily or rosuvastatin 5-10mg daily could be alternative choices. It is essential to monitor liver function tests at baseline and periodically, and check creatine kinase if muscle symptoms develop. The decision to initiate statin therapy should also consider life expectancy, functional status, medication burden, and patient preferences, as these factors become increasingly important in very elderly patients. Statins are beneficial in secondary prevention even in elderly patients, as they reduce the risk of recurrent cardiovascular events by lowering LDL cholesterol and providing pleiotropic anti-inflammatory effects 1.

Key considerations in managing this patient include:

• Evaluating the potential for ASCVD risk reduction with statin therapy
• Assessing adverse effects and drug–drug interactions
• Considering patient frailty and patient preferences
• Monitoring for potential side effects of statin therapy, such as liver enzyme elevations or muscle symptoms
• Adjusting the intensity of statin therapy based on the patient's response and tolerability.

From the FDA Drug Label

In the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT), the effect of atorvastatin calcium on fatal and non-fatal coronary heart disease was assessed in 10,305 patients with hypertension, 40 to 80 years of age Atorvastatin calcium significantly reduced the rate of coronary events [either fatal coronary heart disease or non-fatal MI] with a relative risk reduction of 36% The risk reduction was consistent regardless of age, smoking status, obesity, or presence of renal dysfunction.

The patient in question is 88 years old, which is outside the age range of the patients in the ASCOT trial (40 to 80 years). There is no direct evidence to support the use of statin in this patient. The FDA drug label does not answer the question.

From the Research

Patient Profile

• The patient is an 88-year-old male with a history of:
  • Cerebrovascular accident (CVA)
  • Coronary artery disease (CAD)
  • Atrial fibrillation
  • Left ventricular thrombus
  • Congestive heart failure (CHF)
  • Hypertension

Statin Use in Similar Patient Profiles

• According to 2, high-intensity statins are recommended for patients with atherosclerotic cardiovascular disease (ASCVD), which includes CAD and CVA.
• The study 3 found that statin therapy was associated with a reduction in all-cause and cardiovascular mortality in patients with atrial fibrillation.
• However, 4 states that the evidence is insufficient to determine the balance of benefits and harms of statin use for the primary prevention of CVD events and mortality in adults 76 years or older with no history of CVD.

Considerations for Statin Prescription

• The patient's age (88 years) is a consideration, as 4 notes that the evidence is insufficient to assess the balance of benefits and harms of initiating a statin for the primary prevention of CVD events and mortality in adults 76 years or older.
• However, the patient's history of CAD, CVA, and atrial fibrillation may indicate a benefit from statin therapy, as suggested by 2 and 3.
• The study 5 found that statin underuse was associated with higher risk of all-cause and CV death in patients with atrial fibrillation.

Decision Making

• Considering the patient's complex medical history and the potential benefits of statin therapy, a decision to prescribe a statin should be made on a case-by-case basis, taking into account the patient's individual risk factors and medical history.
• The patient's age and potential for polypharmacy should also be considered when making a decision about statin prescription.
• Further evaluation of the patient's overall health and medical history may be necessary to determine the best course of treatment.