Lipid-modifying therapy in the elderly

Figures & data

Figure 1 Mean odds ratios for treatment with lipid therapy according to age.

Table 1 The Medication Appropriateness Index⁹

1. Is there an indication for the drug?

2. Is the medication effective for the condition?

3. Is the dosage correct?

4. Are the directions correct?

5. Are the directions practical?

6. Are there clinically significant drug–drug interactions?

7. Are there clinically significant drug–disease/condition interactions?

8. Is there unnecessary duplication with other drugs?

9. Is the duration of therapy unacceptable?

10. Is this drug the least expensive alternative compared with others of equal usefulness?

Note: Reproduced with permission from Holmes HM, Hayley DC, Alexander GC, Sachs GA. Reconsidering medication appropriateness for patients late in life. Arch Intern Med. 2006;166:605–609. Copyright © (2006) American Medical Association. All rights reserved.⁹

Figure 2 Hospitalizations for CVD per 100,000 people in the Australian population according to age and sex.

Table 2 Prevalence of CVD risk factors (%) by age and sex in the Framingham Study¹⁶

Age	ECG-LVHa	ECG-LVH	DMb	DM	HTc	HT
	M	F	M	F	M	F
55–64	2.7	1.7	5.5	4.2	26.8	31.5
65–74	3.6	3.2	10.9	7.2	38.0	47.6
75–84	4.2	4.9	13.2	10.2	48.4	59.9
85–94	5.9	9.4	14.2	11.1	47.8	65.6

Notes:

a Electrocardiographic evidence of left ventricular hypertrophy;

b diabetes mellitus (treated for diabetes or blood glucose ≥200 mg/dL);

c hypertension (≥160/95). Coronary heart disease risk factors in the elderly. Kannel WB. © 2002 The American Journal of Geriatric Cardiology. Reproduced with permission of Blackwell Publishing Ltd.¹⁶

Abbreviations: CVD, cardiovascular disease; ECG, electrocardiographic evidence; LVF, left ventricular hypertrophy; DM, diabetes mellitus; HT, hypertension; M, male; F, female.

Figure 3 Cardiovascular risk according to risk factors and total cholesterol levels in the Dubbo study.

Notes: Reference group: not taking antihypertensive medication; systolic pressure 140 mmHg; non-smoking; high-density lipoprotein level 1.10 mmol/L; no diabetes.

Figure 4 Vascular mortality according to age and total cholesterol level in the Prospective Studies Collaboration.

Figure 5 Proportion of private lipoprotein tests in Queensland in 1 year according to age.

Table 3 Long-term risk for atherosclerotic cardiovascular disease by age 80 (from age 50)

Long-term risk category	Absolute risk for atherosclerotic cardiovascular disease (%)
Low	<15
Moderate	15–30
Moderately high	30–44
High	>45

Note: Coronary heart disease risk factors in the elderly. Kannel WB. © 2002 The American Journal of Geriatric Cardiology. Reproduced with permission of Blackwell Publishing Ltd.¹⁶

Figure 6 Meta-analysis of patients with cardiovascular disease aged >60 years according to statin versus placebo treatment.

Note: Reproduced from Roberts CG, Guallar E, Rodriguez A. Efficacy and safety of statin monotherapy in older adults: a meta-analysis. J Gerontol A Biol Sci Med Sci. 2007;62:879–887, by permission of Oxford University Press.²³
Abbreviations: LIPID, the Long-Term Intervention with Pravastatin in Ischaemic Disease (LIPID) Study Group; CARDS, Collaborative Atorvastatin Diabetes Study; HPS, Heart Protection Study; SCAT, Simvastatin/Enalapril Coronary Atherosclerosis Trial; PROSPER, Pravastatin in elderly individuals at risk of vascular disease; 4S, Scandinavian Simvastatin Survival Study; ACAPS, Asymptomatic Carotid Artery Progression Study; CARE, the Cholesterol and Recurrent Events trial; ASCOT-LLA, Anglo-Scandinavian Cardiac Outcomes Trial–Lipid Lowering Arm (ASCOT-LLA); PLAC-I, Pravastatin Limitation of Atherosclerosis in the Coronary arteries I; PLAC-II, Pravastatin Limitation of Atherosclerosis in the Coronary arteries II; AFCAPS/TexCAPS, Air Force/Texas Coronary Atherosclerosis Prevention Study.

Figure 7 Predicted 5-year benefits of LDL cholesterol reductions with statin treatment at different levels of risk in Cholesterol Treatment Trialists’ Collaboration meta-analysis.

Figure 8 Major vascular event rate with statin treatment according to age in Cholesterol Treatment Trialists’ Collaboration meta-analysis.

Figure 9 Reduction in coronary death or hospitalization for myocardial infarction with pravastatin versus placebo treatment.

Notes: Numbers of patients included in the study are provided according to year since randomization for patients treated with either placebo (upper line of X axis) or pravastatin (lower line of X axis). © 2013 Lloyd SM, Stott DJ, de Craen AJ, et al. Long-term effects of statin treatment in elderly people: extended follow-up of the PROspective Study of Pravastatin in the Elderly at Risk (PROSPER). PLoS One. 2013;8:e72642.²⁵
Abbreviation: MI, myocardial infarction.

Figure 10 Mortality reduction in cardiovascular disease patients with statin treatment according to age.

Note: Black bars: no statin treatment; white bars: statin treatment.

Figure 11 Benefits of simvastatin versus placebo treatment in Scandinavian Simvastatin Survival Study.

Note: The Y axis of both graphs refers to proportion alive where 1.00=100%.

Table 4 Guidelines on lipid management in the elderly by different groups: summary

Adult Treatment Panel III of National Cholesterol Education Program	1. Statins recommended for secondary prevention. 2. Clinical judgment used for primary prevention due to unreliable risk scoring assessments.
American Society of Geriatric Cardiology National Institute for Health and Clinical Excellence	Treat individuals at high CVD risk who are otherwise healthy. Clinical assessment used to guide therapy for whom appropriate risk calculator not available.
National Collaborating Centre for Primary Care	People aged 75 or over at increased CVD risk and likely to benefit from statins. Treatment guided by benefits vs risk of treatment, informed preference, comorbidities that may make treatment inappropriate.
European Society of Cardiology/European Atherosclerosis Society	Very limited evidence for treatment above age 80–85 years. Clinical judgment should guide decisions in the very old.

Note: Reprinted from Heart Lung Circ 2014;23. Noaman S, Ibrahim JE, Grenfell R. Prescribing statins for cardiovascular disease prevention in the old: an absence of evidence and an absence of guidelines 619–624. Copyright ©2014 with permission from Elsevier.¹⁴ acids, Class IIa/Level C for statin and fibrate, and Class IIb/Level B for fibrate and n-3 fatty acids.³⁵

Table 5 ESC/EAS recommendations for treatment of dyslipidemia in the elderly

Recommendations	Class of recommendation	Level of evidence
Treatment with statins is recommended for elderly patients with established CVD in the same way as for younger patients.	I	B
Since elderly patients often have comorbidities and have altered pharmacokinetics, it is recommended to start lipid-lowering medication at a low dose and then titrate with caution to achieve target lipid levels which are the same as in the younger patients.	I	C
Statin therapy may be considered in elderly subjects free of CVD, particularly in the presence of one other CV risk factor besides age.	IIb	B

Note: Reprinted from The Lancet 2010;375. Jun M, Foote C, Lv J, et al. Effects of fibrates on cardiovascular outcomes: a systematic review and meta-analysis. 1875–1884. Copyright ©2010, with permission from Elsevier.³⁴

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