Should a statin (HMG-CoA reductase inhibitor) be initiated in a 92-year-old patient for hypercholesterolemia?

From the Guidelines

Starting a statin in a 92-year-old for cholesterol management is generally not recommended. The potential benefits of statins for primary prevention in very elderly patients are limited, as the time needed to achieve cardiovascular risk reduction typically exceeds their life expectancy 1. Additionally, older adults are more susceptible to statin side effects including muscle pain, cognitive effects, and drug interactions due to polypharmacy common in this age group. The risk-benefit ratio becomes less favorable with advancing age, particularly beyond 85 years.

According to the 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults, moderate-intensity statins are recommended in patients >75 y of age and in those who have contraindications/intolerance to high-intensity regimens 1. However, the USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of initiating statin use in adults 76 years and older 1.

Some key points to consider in this decision include:

• The patient's overall health status and life expectancy
• The presence of established cardiovascular disease
• Frailty and comorbidities
• Patient preferences and values
• The potential for statin side effects and drug interactions

Instead of starting a statin, focus should be placed on quality of life, managing existing conditions, and addressing modifiable cardiovascular risk factors through lifestyle measures if appropriate. Any decision about statin therapy in a very elderly patient should involve shared decision-making that accounts for the patient's values, goals of care, and remaining life expectancy.

From the Research

Statin Use in the Elderly

• The US Preventive Services Task Force (USPSTF) recommends statin use for the primary prevention of cardiovascular disease (CVD) in adults aged 40 to 75 years with one or more CVD risk factors and an estimated 10-year CVD event risk of 10% or greater 2.
• However, the USPSTF concludes that the evidence is insufficient to determine the balance of benefits and harms of statin use for the primary prevention of CVD events and mortality in adults 76 years or older with no history of CVD 2.
• A study on statin use and risk for type 2 diabetes found that the increase in incidence of type 2 diabetes in those with major risk factors is approximately 25% for statin use, but the number of CVD events prevented for each excess case of type 2 diabetes is close to or greater than one, indicating that the risk-benefit ratio still strongly favors use of statin therapy 3.

Considerations for Statin Therapy in a 92-Year-Old

• There is limited evidence to support the use of statins for primary prevention of CVD in adults over 75 years old, and the USPSTF recommends against initiating statin therapy in this age group without a history of CVD 2.
• However, if the patient has a history of CVD or is at high risk for CVD events, statin therapy may still be beneficial, and the decision to initiate therapy should be made on a case-by-case basis, taking into account the patient's individual risk factors and health status.
• The safety and efficacy of statin therapy have been established in numerous studies, and the benefits of statin therapy are thought to outweigh the risks for most patients 4.

Risk-Benefit Assessment

• When considering statin therapy in a 92-year-old patient, it is essential to weigh the potential benefits against the potential risks, including the risk of new-onset diabetes, cognitive impairment, and hemorrhagic stroke 3, 4.
• The patient's individual risk factors, such as dyslipidemia, diabetes, hypertension, or smoking, should be taken into account when making the decision to initiate statin therapy 2, 5.