Are You Too Old to Worry About High Cholesterol?

The estimated risk of heart attack and stroke rises to high levels by the time you reach 75 years. Does it make sense for old codgers to take lipid lowering medications like statins?

The skeptical cardiologist attempted to answer the question "Should you take a statin drug if you feel fine over the age of 75 years ?" in 2018.

When I wrote about statins in the elderly in 2018 it was clear that very good evidence from randomized controlled trials supported the use of statin therapy for the primary prevention of nonfatal stroke and heart attack events in elderly individuals 66 to 75 years of age.

I felt the benefits of statin therapy were lower in primary prevention and not clearly shown in individuals over age 75. Risks of statin side effects aren't clearly higher in this age group but the frequent presence of comorbidities and polypharmacy increase side effect possibilities.

For me, the older the patient, the higher the bar for initiating statins. In this population, a search for subclinical atherosclerosis (coronary calcium scan or vascular ultrasound) is particularly helpful in more precisely identifying the patient's personal risk and thus informing the decision.

This approach to personalize treatment in elderly people can often result in “derisking” by identifying those with absent or extremely low coronary calcification those at so low risk that statin therapy may safely be withheld.

In the BioImage study of elderly individuals, for example, absence of coronary artery calcification was noted in 1/3 of individuals and associated with exceptionally low ASCVD event rates

Older, Elderly, or Very Elderly

As I have inexorably aged, I've become more sensitive to the terms authors use to describe the various age groups in these studies. Having reached 70 years, I've reluctantly started referring to myself as an old man but I object to being termed elderly.

In my office, I routinely see 75-year-olds who are remarkably young in appearance, demeanor, and activity levels.

Several organizations have suggested authors use "Age-inclusive language": in their writing and everyday speech.

examples of biased language are “elder” or “elderly”, “senior”, or “the aged”. The new editions of all four style guides advise against using these terms because they evoke negative stereotypes of older adults, which can lead to othering older adults, bias against older adults, and poor outcomes for older adults. Instead of those terms, more neutral phrases are preferred, such as “older adult, “older person,” or “persons over 65.” It is also suggested that fatalistic or negative phrases about the aging population – such as “silver tsunami” – are eliminated from writing, and a preferred phrase used, such as “growth of the aging population.” Generally, it is considered a best practice to use language that is not othering, and that treats aging as a normal human process.

I fear these guidelines for speech come across as a little too "woke" but ultimately when we use a term like elderly or very elderly in scientific writing we are being imprecise. For brevity's sake, I am going to use the term "old codgers" for those over 75 years of chronological age.

If I reach 75 years of age I promise to embrace being called an old codger (defined as an old man who is strange, eccentric, or humorous in some way.) For the purposes of the following definition, codger will be unisex.

New Information

I found one interesting study published since 2018 which lends support to the treatment of old codgers.

The Ezetimibe Lipid-Lowering Trial on Prevention of Atherosclerotic Cardiovascular Disease in 75 or Older (EWTOPIA 75): A Randomized, Controlled Trial uses an alternative to statins that works by inhibiting the absorption of cholesterol in the small intestine.

Japanese investigators randomized almost 4000 individuals >75 years of age with high LDL cholesterol and without a history of coronary disease to either 10 mg ezetimibe or a placebo and followed them for 4 years.

The primary endpoint of sudden cardiac death, myocardial infarction, coronary revascularization, or stroke was reduced by 36%. by ezetimibe. There was no difference in all-cause mortality, stroke, or adverse events between the two groups.

Multiple observational studies have been published and they all show that statin usage is associated with improved cardiovascular outcomes in old codgers but I consider these data meaningless (MOOPs.)

The Bottom Line

If you are >75 years of age and free of any clinical atherosclerotic cardiovascular disease there is little evidence that taking a statin drug will benefit you.

Two large ongoing trials are trying to answer the question.**

Consider getting a coronary artery calcium scan as very low or zero scores lower your individual risk for ASCVD and substantially higher than average scores increase your risk.

Ponder other factors that impact the risks and benefits of statin drugs and have an intense discussion with your doctor that includes these factors.

If you or your doctor have concerns about statin therapy consider taking ezetimibe (Zetia) as an alternative for lipid lowering and ASCVD risk reduction.

If you are still on the fence after this discussion consider a compromise approach that I have outlined here.

Deriskingly Yours,

-ACP

I came across a nice review article on this topic published in early August of this year which notes that:

Upcoming trials will fill this gap on the role of statin therapy. PREVENTABLE trial and the STAREE trial represent two pivotal research efforts in evaluating the efficacy of atorvastatin versus placebo in older populations. The PREVENTABLE trial focuses on 20,000 community-dwelling individuals aged 75 years and older, randomized to atorvastatin 40 mg versus placebo with a follow-up of 5 years duration. The aim is to determine whether statins can reduce the risk of dementia and persistent disability, with secondary outcomes including mild cognitive impairment (MCI) and cardiovascular events. The STAREE trial, a double-blind, randomized, placebo- controlled trial with atorvastatin to recruit around 18,000 participants, targets those aged 70 and older. The primary endpoints are cognitive and physical disability-free survival and major cardiovascular events as well as a broad range of secondary objectives encompassing all-cause death, dementia, cognitive decline, physical disability, MI, stroke, cardiovascular death, cancer, heart failure hospitalization, atrial fibrillation, all-cause hospitalization, need for permanent residential care, and quality of life