What is the risk of myocardial infarction (heart attack) or cerebrovascular accident (stroke) after discontinuing HMG-CoA reductase inhibitors (statins) in geriatric patients over 80 years old?

From the Guidelines

Stopping a statin medication can potentially increase the risk of heart attack or stroke within days to weeks, particularly in geriatric patients over 80 who already have established cardiovascular disease, with the rebound risk beginning as soon as 1-2 weeks after discontinuation. For these high-risk elderly patients, it is crucial to consider the potential consequences of discontinuing statin therapy. According to a recent study published in the Mayo Clinic Proceedings 1, lipid-lowering drugs, specifically statins, are often considered for discontinuation in aging adults, but the cardiovascular benefit continues to be conferred compared with those who do not take or continue on statin therapy.

When considering discontinuation of statin therapy in elderly patients, it is essential to balance cardiovascular risk against life expectancy, quality of life, and medication burden. A study published in the Journal of the American College of Cardiology 1 suggests that discontinuing primary prevention with statin therapy is reasonable to consider in elderly, frail people at increased risk for adverse effects and low chance of benefit because of limited life expectancy. However, common statins like atorvastatin (Lipitor), rosuvastatin (Crestor), and simvastatin (Zocor) should never be stopped abruptly without medical supervision, as they provide anti-inflammatory and plaque-stabilizing effects that protect blood vessels.

Some key points to consider when discontinuing statin therapy in elderly patients include:

• The potential for rapid loss of protective effects, leading to plaque instability and increased inflammation
• The rebound increase in LDL cholesterol, which typically occurs within 2-4 weeks
• The importance of careful monitoring and possibly gradual tapering when discontinuing statin therapy
• The consideration of alternative lipid-lowering strategies, such as lower doses, alternate-day dosing, or different medications like ezetimibe.

Ultimately, the decision to continue or discontinue statins in very elderly patients should be made on a case-by-case basis, taking into account the individual patient's risk factors, life expectancy, and quality of life, as well as the potential benefits and risks of statin therapy, as suggested by the study published in the Mayo Clinic Proceedings 1.

From the Research

Risk of Heart Attack or Stroke after Stopping Statin Medication

• The risk of heart attack or stroke after stopping statin medication, especially in geriatric patients above the age of 80, is a concern due to the potential for increased levels of low-density lipoprotein (LDL) cholesterol [ 2, 3 ].
• Studies have shown that statins are effective in reducing the risk of atherosclerotic cardiovascular disease (ASCVD) and are recommended as a first-line therapy for the primary and secondary prevention of ASCVD [ 2, 3 ].
• However, there is limited data on the specific risk of heart attack or stroke after stopping statin medication in geriatric patients above the age of 80 [ 4 ].

Alternative Treatment Options

• For patients who cannot tolerate statins due to adverse effects, alternative treatment options such as ezetimibe and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors may be considered [ 2, 5,6,3 ].
• PCSK9 inhibitors have been shown to significantly reduce LDL cholesterol levels and decrease the risk of ASCVD events when added to maximally tolerated statin therapy [ 2, 5,6,3 ].
• Ezetimibe has also been shown to reduce LDL cholesterol levels and decrease the risk of ASCVD events when added to statin therapy [ 2, 5,6 ].

Timing of Risk

• The exact timing of the risk of heart attack or stroke after stopping statin medication is not well established, and more research is needed to determine the specific timeframe [ 4 ].
• However, it is recommended that patients who are at high risk of ASCVD events, such as those with a history of cardiovascular disease, continue to receive lipid-lowering therapy, including statins and/or alternative treatments, to reduce their risk of heart attack or stroke [ 2, 6,3 ].