From the Guidelines
The 86-year-old patient with an LDL of 148 mg/dL should not be started on statins unless they have established cardiovascular disease or very high risk factors, as the potential benefits of statins diminish with advanced age, while the risks of side effects and drug interactions increase. When considering statin therapy in older adults, it's essential to weigh the potential benefits against the potential harms, including muscle pain, liver enzyme elevations, and cognitive effects, which can significantly impact quality of life 1. According to the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline, 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.
Key considerations in this decision include:
- The patient's overall cardiovascular risk and life expectancy
- Their functional status and ability to tolerate potential side effects
- Their preferences regarding prevention versus quality of life considerations
- The presence of established cardiovascular disease or very high risk factors
If statin therapy is deemed appropriate, a moderate-intensity statin like atorvastatin 10-20 mg daily or rosuvastatin 5-10 mg daily may be considered, starting at a lower dose than would be used in younger patients 1. Close monitoring for side effects and drug interactions is essential, with follow-up lipid panels and liver function tests within 4-12 weeks of initiation. The USPSTF also recommends considering the patient's specific circumstances and their preference for a potential small benefit relative to the potential harms and inconvenience of taking a lifelong daily medication 1.
From the Research
Statin Therapy for an 86-Year-Old with LDL of 148
- The decision to initiate statin therapy in an 86-year-old patient with an LDL of 148 should be based on a patient-clinician discussion, considering the patient's overall ASCVD risk and other clinical factors that influence life expectancy and quality of life 2.
- Age alone should not be a deterrent to statin therapy in older patients, as moderate to high intensity statin therapy has been shown to decrease cardiovascular event rates in older patients with or at risk for ASCVD 2.
- However, available information is inadequate to guide decisions regarding statin therapy in patients over 85 years of age 3.
- The benefits of statin therapy in reducing ASCVD risk should be weighed against possible adverse effects, such as new onset diabetes, myopathy, and medication interactions, which may be more significant in the elderly 4, 3.
- Imaging studies of subclinical atherosclerosis may improve specificity of statin therapy to prevent ASCVD in the elderly in primary prevention 3.
- The ACC-AHA and USPSTF cholesterol guidelines do not recommend statin therapy for primary prevention in patients over 75 years of age, emphasizing the need for physician judgment and shared decision-making 3.
- Lower doses of statins may be required in the elderly due to drug interactions and differences in metabolism related to aging 5.