At what age should Atherosclerotic Cardiovascular Disease (ASCVD) management be stopped?

Management of Atherosclerotic Cardiovascular Disease (ASCVD) in Older Adults

For patients >75 years of age with established ASCVD, it is reasonable to continue statin therapy if they are already tolerating it, but initiation of statin therapy should be individualized based on potential benefits, adverse effects, drug-drug interactions, and patient preferences.

Age-Based Recommendations for ASCVD Management

Adults ≤75 Years of Age

• High-intensity statin therapy should be initiated or continued as first-line therapy in adults ≤75 years with clinical ASCVD, unless contraindicated (Class I, Level A) 1
• Target is to reduce LDL-C levels by ≥50% from baseline 1
• If high-intensity statin therapy is contraindicated or not tolerated, moderate-intensity statin therapy should be used as the second option 1

Adults >75 Years of Age

• For those already on statin therapy:

  • Continue statin therapy if well-tolerated 1
  • No need to discontinue based solely on age 1

• For initiating new therapy in those >75 years:

  • Moderate-intensity statin therapy is preferred over high-intensity 1
  • Decision should be based on:
    • Potential ASCVD risk-reduction benefits
    • Risk of adverse effects
    • Drug-drug interactions
    • Comorbidities
    • Life expectancy
    • Patient preferences

Evidence Supporting These Recommendations

• In clinical trials, individuals >75 years showed reduction in ASCVD events with moderate-intensity statin therapy compared to control 1
• However, there was no clear evidence of additional benefit from high-intensity statin therapy in this age group 1
• Older participants in randomized controlled trials were likely healthier than many older individuals in the general population, necessitating individualized approaches 1

Risk Assessment in Older Adults

For patients >75 years without established ASCVD:

• RCT evidence for initiating statins for primary prevention is limited 1
• Consider additional factors:
  • Increasing comorbidities
  • Safety considerations
  • Priorities of care
  • Life expectancy
  • Functional status

Clinical Decision-Making Algorithm for ASCVD Management in Adults >75 Years

1. For patients already on statin therapy:

   • Continue if well-tolerated
   • Consider dose reduction if experiencing side effects

2. For patients not on statin therapy:

   • Assess clinical ASCVD status:
     • If established ASCVD: Consider moderate-intensity statin
     • If no established ASCVD: Weigh potential benefits against risks

3. Factors favoring statin initiation in those >75:

   • Good functional status
   • Life expectancy >5 years
   • High cardiovascular risk factors
   • Family history of premature ASCVD
   • Personal preference for aggressive prevention

4. Factors favoring conservative approach:

   • Limited life expectancy
   • Multiple comorbidities
   • Polypharmacy with high risk of drug interactions
   • History of statin intolerance
   • Frailty or poor functional status

Common Pitfalls to Avoid

• Automatic discontinuation of statins based solely on age
• Failure to consider quality of life and functional status in decision-making
• Overlooking drug interactions that are more common in older adults
• Not reassessing benefit-risk ratio periodically as patients age
• Ignoring patient preferences regarding prevention strategies

Monitoring Recommendations

• Measure lipid levels 4-6 weeks after initiating or changing therapy 2
• Monitor annually once at goal, with more frequent monitoring (every 3-6 months) for patients not at goal 2
• Check liver enzymes (ALT) 8-12 weeks after starting therapy or dose change 2
• Consider checking CK in patients with high risk for myopathy (elderly with comorbidities, patients on interacting drugs) 2

Remember that while there is no specific age to universally stop ASCVD management, treatment decisions for patients >75 years should carefully balance potential benefits against risks, with consideration of overall health status and patient preferences.