In an 88‑year‑old woman taking atorvastatin 5 mg orally daily with a lipid panel showing total cholesterol 160 mg/dL, triglycerides 125 mg/dL, HDL cholesterol 34 mg/dL, and LDL cholesterol 101 mg/dL, should the statin be continued, intensified, or discontinued?

Statin Management in an 88-Year-Old Woman with Low HDL

In this 88-year-old woman with functional decline (implied by very low HDL and advanced age), the statin should be discontinued, as the potential benefits no longer outweigh the risks in a patient with limited life expectancy and already low LDL cholesterol. 1

Age-Specific Considerations for Statin Continuation

For adults over 75 years, it is reasonable to stop statin therapy when functional decline, multimorbidity, frailty, or reduced life expectancy limits potential benefits. 1 At 88 years old, this patient falls well beyond the age threshold where evidence for primary prevention benefit becomes sparse and uncertain, with only 8% of statin trial participants being over 75 years. 1

Key Clinical Context

• Her LDL is already at 101 mg/dL on only 5 mg atorvastatin daily, which is a very low dose suggesting either excellent response or minimal baseline elevation. 2
• The critically low HDL of 34 mg/dL is a marker of metabolic dysfunction and potentially poor overall health status, which increases the likelihood of functional decline and frailty. 3
• At age 88, life expectancy is typically less than 3 years, and statins require years to accrue cardiovascular benefits while risks remain immediate. 1

Evidence Supporting Discontinuation

The American Geriatrics Society recommends considering statin discontinuation in patients with poor health status, including those with short life expectancy, as statins should only be considered in primary prevention for patients with at least 3 years of life expectancy. 1 The 2019 ACC/AHA guidelines support this approach, noting that for adults over 75 years, functional decline, multimorbidity, frailty, or reduced life expectancy limits potential benefits. 3, 1

Primary vs. Secondary Prevention Context

The critical question is whether this patient has established atherosclerotic cardiovascular disease (ASCVD). 1

• If this is primary prevention (no prior MI, stroke, TIA, coronary revascularization, or peripheral arterial disease), discontinuation is strongly supported at age 88. 1
• If this is secondary prevention with established ASCVD, the decision becomes more nuanced, but even then, moderate-intensity therapy is the maximum recommended in patients over 75 who are not tolerating therapy well. 1

Practical Discontinuation Algorithm

Step 1: Assess Prevention Category

• Review medical history for prior MI, stroke, TIA, coronary revascularization, or peripheral arterial disease to determine if this is primary or secondary prevention. 1

Step 2: Evaluate Functional Status

• Assess for functional decline, frailty, multimorbidity, or polypharmacy (≥5 medications). 1
• The very low HDL of 34 mg/dL suggests metabolic dysfunction that may correlate with poor functional status. 3

Step 3: Estimate Life Expectancy

• At age 88, life expectancy is typically less than 3 years, which is below the threshold where statin benefits accrue. 1

Step 4: Make the Decision

• For primary prevention at age 88 with likely limited life expectancy: Discontinue the statin. 1
• For secondary prevention with good functional status: Consider continuing at the current low dose (5 mg atorvastatin), but do not intensify. 1

Why Not Intensify Therapy?

Intensification is not appropriate in this patient for multiple reasons:

• The 2013 ACC/AHA guidelines recommend against using specific LDL targets, instead focusing on statin intensity based on risk category. 3
• Even if LDL targets were used, her LDL of 101 mg/dL would not mandate intensification, as the optional goal of <70 mg/dL is reserved for very high-risk patients with acute coronary syndromes. 3
• Advanced age (especially >80 years) is a predisposing characteristic for statin-associated adverse effects, including muscle symptoms and fatigue. 3, 4
• The very low HDL of 34 mg/dL suggests she may benefit more from addressing metabolic factors (diet, exercise if feasible) rather than further LDL lowering. 3

Addressing the Low HDL

The HDL of 34 mg/dL is concerning and warrants evaluation for secondary causes:

• Assess for uncontrolled diabetes, as diabetic patients with dyslipidemia often have low HDL. 3
• Evaluate thyroid function, as hypothyroidism can cause low HDL. 3, 5
• Review medications that may lower HDL (beta-blockers, thiazide diuretics). 3

However, at age 88 with likely limited life expectancy, aggressive treatment of low HDL with fibrates or niacin is not recommended, as these agents have not been shown to reduce ASCVD events when added to statins in randomized trials, and they carry significant risk of adverse effects in elderly patients. 3

Common Pitfalls to Avoid

• Do not continue statins reflexively until death in elderly patients without reassessing indication, as medications are often continued inappropriately in end-of-life care. 1
• Do not use LDL targets to drive therapy intensification in elderly patients, as the 2013 ACC/AHA guidelines moved away from treat-to-target approaches. 3
• Do not ignore the very low HDL, but recognize that aggressive treatment is unlikely to benefit a patient with limited life expectancy. 3, 1
• Do not assume all patients over 75 should stop statins—the decision depends on functional status, life expectancy, and whether this is primary or secondary prevention. 1

Shared Decision-Making

The final decision should involve discussion of goals of care, treatment priorities, and patient preferences. 1 Discontinuation may improve quality of life by reducing pill burden, medication costs, and potential side effects, particularly in a frail elderly patient. 1 If the patient values cardiovascular prevention and has good functional status with established ASCVD, continuing the current low dose (5 mg atorvastatin) is reasonable, but intensification is not warranted. 1