The role of statin therapy in older adults: best practices and unmet challenges

ABSTRACT

Introduction

Cardiovascular disease (CVD) is associated with significant morbidity, functional decline, and mortality in older adults. The role of statins for primary CVD prevention in older adults remains unclear, largely due to systematic exclusion of these individuals in trials that inform current practice guidelines, leading to conflicting national and international practice recommendations for statin use for primary prevention of CVD in adults aged 75 and older.

Areas covered

In this narrative review, we performed a literature review utilizing PubMed, and ultimately focus on seven major national and international guidelines of lipid lowering therapy. Through the lens of two clinical cases, we review physiologic changes in lipid metabolism with aging, discuss the relationship between cholesterol and cardiovascular events in older adults, examine the national and international guidelines and the available evidence informing these guidelines for statin use in primary prevention of CVD in older adults. Finally we review practical clinical considerations for drug monitoring and deprescribing in this population.

Expert opinion

Guidelines for the use of statins for primary CVD prevention in older adults is conflicting. Collectively, evidence to date suggests statin therapy may be beneficial for primary CVD prevention in older adults free of life-limiting comorbidities. Randomized controlled trials are currently underway to address current evidence gaps.

KEYWORDS:

• Statins
• prevention
• elderly
• frailty
• cardiovascular disease

Article highlights

• Evidence for the use of statins for primary prevention of cardiovascular disease (CVD) in older adults, particularly those over the age of 75, is limited due to exclusion of these individuals from informing clinical trials.

• Leading national and international guidelines for the management of cholesterol for the primary prevention of CVD provide variable recommendations as to the method of calculating risk of future atherosclerotic cardiovascular disease (ASCVD) and optimal age ranges for statin therapy.

• The relationship between total cholesterol and low-density lipoprotein cholesterol (LDL-C) with cardiovascular outcomes in older adults is unclear, which may suggest that the benefit of statins in this population is related to their anti-inflammatory effect.

• There is limited evidence to suggest that statin use is associated with statin-associated muscle symptoms (SAMS) or cognitive impairment in older adults, and the overall cardiovascular benefit of statin therapy outweighs the slightly increased of diabetes mellitus in this population.

• Limited evidence suggests that statins are beneficial in appropriately selected older adults. Important considerations to assist clinicians, patients, and caregivers with decision-making include statin time to benefit (TTB), life expectancy, frailty, multimorbidity, polypharmacy, and patient preferences, which can be elicited with the use of the Geriatric 5 M’s.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

AR Orkaby is funded by the U.S. Department of Health and Human Services National Institutes of Health National Institute on Aging [P30AG031679 and R01AG081287] and the U.S. Department of Veterans Affairs [IK2CX001800].