From the Guidelines
The decision to start a statin in an 83-year-old should be individualized based on their overall health status, life expectancy, and cardiovascular risk factors, with consideration of the potential benefits and risks, as recommended by the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol 1. When considering statin therapy in an 83-year-old, it is essential to evaluate the potential for ASCVD risk reduction, adverse effects, and drug-drug interactions, as well as patient frailty and patient preferences, as stated in the guideline 1.
- For healthy 83-year-olds with good functional status and life expectancy of more than 5 years, a moderate-intensity statin like atorvastatin 10-20mg daily or rosuvastatin 5-10mg daily may be reasonable if they have established cardiovascular disease or multiple risk factors.
- However, for frail elderly patients with limited life expectancy or multiple comorbidities, the potential benefits may not outweigh the risks of side effects like muscle pain, cognitive effects, and drug interactions. Before starting treatment, consider baseline liver function tests and assess for potential drug interactions with the patient's current medications, and start with a lower dose and monitor for side effects, particularly muscle pain or weakness, as the benefit of statins decreases with advancing age, and the time needed to see cardiovascular benefits (typically 2-5 years) should be weighed against the patient's life expectancy and goals of care 1. The USPSTF concludes that the balance of benefits and harms of initiating statin use for the primary prevention of CVD events in adults 76 years and older without a history of CVD cannot be determined 1, which further emphasizes the need for individualized decision-making. A thorough discussion with the patient about potential benefits, risks, and their personal preferences is essential before initiating statin therapy, taking into account the latest guideline recommendations 1.
From the Research
Statin Therapy in Older Adults
- The decision to initiate statin therapy in older adults should be based on the patient's overall atherosclerotic cardiovascular disease (ASCVD) risk and weighed against other clinical factors that influence the patient's 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.
- Cardiac biomarkers and coronary calcium scoring can be used to identify older patients at higher ASCVD risk who may benefit from statin therapy 2.
Primary Prevention in Older Adults
- The benefit of statins in primary prevention for older patients is not certain, and their prescription in this setting should only be considered case by case, taking into consideration physiological status, co-morbidities, level of risk, and expected life expectancy 3.
- There are no randomized controlled trials in persons older than 80 years at baseline, and trial evidence in primary prevention is less clear 4.
- Available data do not imply specific harms in older patients, and judicious primary prevention is possible, but treatment decisions should be individualized and take into account the patient's overall health and preferences 4.
Secondary Prevention in Older Adults
- Statin trials in secondary prevention consistently demonstrate significant coronary heart disease risk reduction in the elderly up to age 80 years 5.
- Statins have proven benefit in the elderly in those with coronary heart disease and diabetes mellitus, and lower doses of statins may be required in the elderly due to drug interactions and differences in metabolism related to aging 5.
- The benefits of statin therapy in the elderly clearly outweigh the low risk of serious side effects, and statin treatment should be started in patients with ASCVD and judiciously in primary prevention 5, 4.