Clinical Inquiries

Should we treat elevated cholesterol in elderly patients?

Korsen N,Nowicki E,Thering A,Solomos N. J Fam Pract 2002 Aug;51(8):680.

Evidence-based Answer

HMG-CoA reductase inhibitors, or statins, have been shown to decrease all-cause mortality in individuals aged 65 and older with known coronary heart disease (CHD) and elevated cholesterol levels. (Grade of recommendation: A, based on randomized controlled trials.) The clinical benefit of statin use in older persons without known CHD, however, is uncertain. Decisions about testing for lipid levels and treatment should include discussions with the patient about the potential benefits and risks of treatment, taking into account the individual’s overall risk of CHD. (Grade of recommendation: C, based on extrapolations from cohort studies.)

Evidence-based Summary

Two randomized controlledtrials and 1 cohort study demonstrated a decrease in all-cause mortality in individuals aged 65 and older with known CHD by treating elevated cholesterol levels with either pravastatin or simvastatin.1-3 The overall decrease in absolute risk of death was similar (range, 4.1%–6.2%; numbers needed to treat [NNT] = 17–25). The LIPID trial demonstrated a reduction in CHD-related death (relative risk [RR] = 0.76; 95% CI, 0.62–0.93; NNT = 37) and myocardial infarctions (RR = 0.74; 95% CI, 0.60–0.91; NNT = 36) in elderly patients taking pravastatin 40 mg once daily for 6 years compared with placebo.3

Unfortunately, no comparable evidence is available to guide practitioners in their care of older patients without known CHD. A 1993 report on results of the Framingham study showed the association between all-cause mortality and cholesterol level only in individuals younger than 50 years.4 Two other cohort studies showed an association between elevated cholesterol levels and increased CHD mortality.5,6 It is unclear whether all-cause or CHD mortality is the better outcome to measure.

The best available evidence addressing the benefit of lowering lipid levels in persons with elevated cholesterol but without CHD is from the West of Scotland Coronary Prevention study, which included patients aged 45 to 64 years.7 This study showed a 0.5% reduction in CHD mortality (NNT = 200) and a 0.9% reduction in all-cause mortality (NNT = 111). Neither reduction reached statistical significance.

Several reports have demonstrated that statins safely and effectively lower cholesterol levels in patients aged 65 and older.1-3,8,9 Moreover, statins do not decrease health-related quality of life.10 Approximately 1% to 4% of those who take statins experience side effects, including abnormal liver function, arthralgias, myalgias, rash, sinusitis, and diarrhea.

Clinical Commentary

I inform older adult coronary heart disease (CHD) patients that lowering their cholesterol level will significantly decrease their risk of recurrent myocardial infarction, cardiac death, and the need for coronary revascularization procedures. Importantly, I stress that these effects occur within 2 years of initiating therapy.

For dyslipidemic older patients without CHD, the benefits of lipid-lowering therapy are harder to quantify. Although patients with established CHD and elevated cholesterol levels show the most significant reduction in CHD events, sequential lipid-lowering trials have shown benefits in lower risk populations as well. Additionally, we now have data (from the WOSCOPS and AFCAPS/TEXCAPS trials) demonstrating some effectiveness of lipid-lowering therapy in reducing the risk of a first coronary event. However, no prospective studies demonstrating similar advantages in a geriatric population have been published. For these individuals, I am more likely to give diet therapy, weight loss (if overweight), and exercise a longer trial, as long as lipid levels continue to improve. I give stronger consideration to the use of cholesterol-lowering medications (primarily statins) in patients with two or more CHD risk factors. I also consider comorbidity and life expectancy, keeping in mind that life expectancy for men age 80 years is 7.5 years, and for women 9.1 years (1991 CDC data).

Over time, we have become more comfortable identifying those elderly patients with CHD that are appropriate for coronary revascularization procedures. With the help of future prospective randomized controlled trials (such as the Fluvastatin Assessment of Morbidity-Mortality in the Elderly and the Prospective Study of Pravastatin in the Elderly at Risk trials), we may gain similar confidence in our decisions to treat or not treat dyslipidemias in older adults without CHD.

Recommendations from Others

The National Cholesterol Education Program published its updated guidelines in 2001, lending support for statin treatment of elevated low-density lipoprotein cholesterol levels in selected men aged 65 or older and women aged 75 or older without CHD.11 The target low-density lipoprotein level varied from 100 to 160 mg/dL depending on presence of other cardiac risk factors. The recommendation emphasized lifestyle changes, noninvasive testing for subclinical atherosclerosis, and consideration of treatment for individuals with extensive subclinical disease or multiple risk factors, rather than focusing merely on chronological age.

References

  1. Pedersen TR, Wilhelmsen L, Faergeman Oet al. 2000. Volume 86. Page(s): 257-62.
  2. Miettinen TA, Pyorala K, Olsson AGet al. 1997. Volume 96. Page(s): 4211-8.
  3. Hunt D, Young P, Simes Jet al. 2001. Volume 134. Page(s): 931-40.
  4. Kronmal RA, Cain KC, Ye Zet al. 1993. Volume 153. Page(s): 1065-73.
  5. Rubin SM, Sidney S, Black DMet al. 1990. Volume 113. Page(s): 916-20.
  6. No author listed. American College of Physicians. Clinical Guideline: Part 1. 1996. Volume 124. Page(s): 515-7.
  7. Shepherd J, Cobbe SM, Ford Iet al. 1995. Volume 333. Page(s): 1301-7.
  8. Chan P, Lee CB, Lin TSet al. 1995. Volume 8. Page(s): 1099-104.
  9. Chan P, Huang TY, Tomlinson Bet al. 1997. Volume 37. Page(s): 496-501.
  10. Santanello NC, Barber BL, Applegate WBet al. 1997. Volume 45. Page(s): 8-14.
  11. No author listed. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection. Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Bethesda, MD: National Institutes of Health, National Heart, Lung, and Blood Institute; May 2001. NIH publication 01-3670. Available at: http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3_rpt.htm..