Would an 81-year-old woman with a history of cardiovascular disease benefit from statin therapy, given the limitations of the Atherosclerotic Cardiovascular Disease (ASCVD) risk score for individuals over 79 years old?

Statin Therapy for an 81-Year-Old Woman with Cardiovascular Disease

Statin therapy should be continued in an 81-year-old woman with a history of cardiovascular disease, as evidence strongly supports the efficacy of statins for secondary prevention in elderly patients. 1, 2

Secondary Prevention in Elderly Patients

For patients with established cardiovascular disease (secondary prevention):

• RCT evidence clearly supports the continuation of statin therapy beyond 75 years of age in persons already taking and tolerating these drugs 1
• The PROSPER trial specifically assessed statin benefits in elderly individuals and demonstrated improved outcomes among elderly patients with known vascular diseases 1
• Moderate-intensity statin therapy is supported by substantial evidence for secondary prevention in individuals with clinical ASCVD who are >75 years of age 1, 2

Approach to Statin Therapy in This Patient

Assessment:

1. Confirm cardiovascular disease history - This patient has established cardiovascular disease, making her a candidate for continued statin therapy
2. Evaluate current statin tolerance - If already on statin therapy and tolerating it well, continuation is strongly recommended 2
3. Consider comorbidities and life expectancy - Assess for frailty, multiple comorbidities, and drug interactions 2

Recommended Statin Regimen:

• Moderate-intensity statin is preferred over high-intensity in patients >75 years 1, 2
• Options include:
  • Atorvastatin 10-20 mg daily
  • Rosuvastatin 5-10 mg daily
  • Simvastatin 20-40 mg daily
  • Pravastatin 40-80 mg daily 2

ASCVD Risk Score Limitations and Alternative Approaches

While the ASCVD risk calculator is limited to ages 40-79:

• For secondary prevention, risk calculation is unnecessary as the patient already has established cardiovascular disease
• The benefit of statins for secondary prevention in elderly patients is well-documented regardless of risk score 1

Monitoring and Follow-up

• Annual lipid profile to monitor response to therapy 2
• Monitor for adverse effects, particularly muscle symptoms
• Consider baseline liver function tests and creatine kinase if risk factors for myopathy exist 2
• Avoid high-dose simvastatin with medications like amiodarone due to potential drug interactions 2

Important Considerations and Caveats

• Different guidelines have varying recommendations for statin therapy in elderly patients, but all support continuation of statins for secondary prevention in those >75 years 1
• The National Institute for Health and Care Excellence (NICE) guideline specifically recommends atorvastatin 20mg for individuals ≥85 years with cardiovascular disease 1, 2
• Avoid initiating high-intensity statin therapy for secondary prevention in individuals >75 years of age unless specifically indicated 1
• Consider drug-drug interactions carefully, as elderly patients often take multiple medications 2

By continuing moderate-intensity statin therapy in this 81-year-old woman with cardiovascular disease, you can provide evidence-based care that reduces her risk of future cardiovascular events while minimizing potential adverse effects.