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Statins in high risk older people

 

Clinical bottom line

Statins are prescribed at lower levels in those older patients who are both older, and who are at higher risk. There is an inverse relationship between prescribing statins and cardiovascular risk in older people.


Background

Statins are known to be effective for lowering cholesterol, and for reducing the risk of future cardiovascular events. Their efficacy has been demonstrated in numerous clinical trials of high quality, and they have been shown to have beneficial effects on those with elevated, and normal cholesterol levels (in Industrialised countries). Across different subgroups of patients statins have similar effects. Clinical guidelines recommend the use of statins in people with high individual baseline risks.

There remains considerable debate about extending the use of statins to older elderly patients, despite good evidence that statins are effective in older patients.

Reference


DT Ko et al. Lipid-lowering therapy with statins in high-risk elderly patients. JAMA 2004 291: 1864-1870.


Study

The geriatric Ontario Longitudinal database linked several healthcare databases with follow up of mortality over time. It includes 1.4 million residents of Ontario alive and 66 years or older in 1998. Information was obtained on medicines prescribed in the year before the cohort began.

The cohort were those at high risk of future cardiovascular events, with a history of cardiovascular disease or diabetes. Patients with a history of cancer within five years were excluded. The final cohort was of 396,000 persons.

A baseline risk index was created using multiple logistic regression models, and stratified at 25%, 50% and 75% percentiles of death. Low, intermediate and high risk patients were identified.

Results

Two-thirds of patients in the cohort had cardiovascular disease, 18% diabetes, and the remainder had both conditions. Half were women, and the average age was 75 years. Statins were prescribed in 19%.

Patients who were older, or at higher baseline risk of dying over the next three years were less likely to have a statin prescribed. Figures 1-3 show the relationship between observed three-year mortality and statin prescription for the age groups 66-74, 75-80 and 81 years and older groups.

Figure 1: Relationship between three year mortality and statin prescription for 66-74 group

Figure 2: Relationship between three year mortality and statin prescription for 75-80 group

Figure 3: Relationship between three year mortality and statin prescription for 81 years and older group

Progressively lower use of statins in patients with higher cardiovascular risk existed across the full spectrum of risk, and across the entire spectrum of age.

Comment

This is a paradox, though one that has explanations. Older elderly people and those at very high risk probably have other health problems, possibly of a more immediate importance than future cardiovascular events. In those circumstances, prescribing a statin is likely to be low on the list of priorities, particularly where many drugs are already prescribed, or where compliance may be seen as a problem.

The paradox may also be a snapshot highlighting prescribing drag. Though initiation of statins in older people may not be seen as a priority, it is unlikely that statins started in younger people will be discontinued as they grow older.

Nevertheless, more and better advice on how or whether to prescribe statins to older people at high risk would be welcomed by many prescribers.