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?
Thanks for your views on statins for old codgers. I'm doing research for a book on polypharmacy and prescription medication in later life. I've interviewed let's say the 'young old' , in their sixties, towards the start of their medication journey and found considerable reluctance to start taking a statin having been told that their cholesterol , plus QRISK3 score ( which many didn't fully understand) put them at heightened risk for a stroke or heart attack. Possible side effects, the perceived influence of Big Pharma, taking a pill for life - all given as reasons to decline. The compromise approach you suggest could convince, but I'm not sure many would have enough time, or the confidence, to have a full discussion in a snatched 10 minute GP consultation, and a request for a referral for a coronary artery calcium scan would likely be be refused on account of cost. Certainly worth considering though.
Good points and studies cited here. Thank you. I recall a study cited below (cohort) that suggested STOPPING statins in those over age 75 who are already taking them was associated with more major cardiovascular events than continuing them. So I rarely deprescribe statins in this age group without another reason. Does that sound about right?
I would not use that cited observational study to guide your approach.
For primary prevention if the individual feels great and wants to continue taking the med then given the equipoise in this area it is reasonable to continue lipid lowering therapy. Many that I see who are >75 years want to stop medications due to concern about perceived or potential side effects, polypharmacy, etc. and if at or below average ASCVD risk for age (CAC helpful for knowing this with greater certainty) I think deprescribing make sense.
There are so many limitations to the observational data it is impossible to be confident that stopping statins caused increased risk of MACE and the authors of that JAMA have a lengthy paragraph summarizing them. In addition, this comment in response to the article points out that hip fractures, non cardiovascular death and frailty much more common in the group who stopped statins:
"In this recent article 1, Thompson et al. reported an association between statin discontinuation and major cardiovascular events (MACE) in a national cohort study of people aged ≥ 75 years (median age 79 years) on long-term statin therapy. We wish to comment on the main results of this study. First, in relative terms, the association between statin discontinuation and MACE both in primary prevention (PP) and in secondary prevention (SP) was moderate (risk ratio: RR: 1.37 and 1.22, respectively). More importantly, the association was not MACE-specific as people with statin discontinuation, in PP and SP, had higher risks of hip fracture (RR: 1.90 and 1.73, eTable 19) and of non-cardiovascular mortality (RR: 2.80 and 2.58, eTable 18). A strong association (RR ~ 2.0) between statin discontinuation and these later two non-statin dependent events is a clue that statin discontinuation is not the cause of poor health outcomes in the older population. Statin discontinuation might rather be the consequence of poor health status. Second, in absolute terms, the weighted rate difference between people with and without statin discontinuation was ten-times lower for MACE than for non-cardiovascular mortality (Table 3 vs. eTable 18) both in PP (9 vs. 87 ) and SP (13 vs. 133). We believe that such a high rate difference can not be statin-mediated. In case of statin discontinuation, the person number needed for one excess non-cardiovascular death vs. one excess MACE was thus ten-times lower both in PP (11 vs. 112 per 1.000 person-years) and in SP (8 vs. 77 per 1.000 person-years). Third, frailty could not be assessed using the study register data. In the discussion, the authors state the hypothesis that statin discontinuation is a marker of frailty and poorer health, and they mention that frailty may be a relevant confounder. We fully agree, and we believe that the reported E-value for 2 does not rule out a confounding by frailty, as frailty is proved to be strongly associated one the one hand with statin discontinuation 2, and on the other hand with MACE 3, hip fractures 4 and all-cause mortality 5.
Such observational and confounded data should not lead to causal interpretation. We agree that robust evidence from randomized controlled trails on statin discontinuation are deeply needed. Meanwhile, we suggest that physicians keep continuing statin discontinuation in older people."
I used the term overseasoned citizen. Mentally I function as a 13-year-old still trying to figure out life, the DMV claims that I'm 80, and my back feels like I'm 113.
I'm an old lady at age 77. Although I was encouraged to take statins with a total cholesterol of around 200, I always declined. No history of CVD and the only family history was my mother who had an acute MI in her late 80s after years of poorly controlled diabetes, so I just didn't see the need. About 2 years ago our family switched entirely to grass fed/finished meats. My last bloodwork showed that my total cholesterol has dropped 50 points with a corresponding drop in LDL. No idea whether there is a correlation there but it's really the only change that I have made. I enjoy your columns as a now retired cardiac/ER RN of over 40 years.
I reply as an official old codger: I just retired this year from full time cardiology practice at age 74. When people ask me why I retired, I say "because I'm old". In reality, I could not persuade my employer to remove me from the call schedule and give me a four day work week. Nor did I I want to go to another practice and start a new book of patients. Didn't really want to retire; still love the field and my patients! Just wanted more free time, and no more CYA calls in the middle of the night.
The PREVENTABLE trial and the STAREE trial are both looking at cognitive function, which is very interesting. As I lectured to house staff and gave CME talks to physicians, I found a belief that serum lipoproteins are somehow linked to cholesterol levels in brain membranes, thereby adversely affecting brain function. (Also, one of my colleagues told our PA that we shouldn't lower cholesterol too much so there is some left to make sex hormones.)
Patients often believe that statins worsen memory, and can find "experts" on the internet who agree.
I don't expect these trial to show a cognition benefit, but if they do, another huge indication for statins. But just showing no adverse effect will help.
p.s. I take a statin plus ezetimibe to keep my LDL about 70, despite no CAD history. I elected to do this without a calcium score, as long as I am free of side effects. I will never know what would have happened without treatment.
It's quite sad that what you experienced "I could not persuade my employer to remove me from the call schedule and give me a four day work week" is the norm with cardiology practices. I was very fortunate to be able to transition to a position with no call 4 years ago.
But it required an immense effort to get the people at the top of the organization to think outside the box and let me transition to an unorthodox part-time hybrid position.
Allowing more senior cardiologists to go to no call and part-time keeps extremely valuable , experienced and wise physicians in the work force. it also puts the physician in a space where can appreciate more the time spent with patients.
Your approach to primary prevention is one many cardiologists pursue as we have experienced over many years and in many patients how effective and safe it is.
How about we address who funded these studies number one? Number two, let’s make sure each of these studies takes the absolute risk reduction as the primary assessment with regard to risk/benefit ratios and not the relative risk reduction to stop fooling American consumers about minimal mortality benefits.
I'd love to read your take about the opposite end of the age spectrum in an article you title "Are you too young to consider primary prevention of ASCVD?"
I’m a 60 year old codger, and have decided after some drug reactions last year (statin vs corticosteroid vs a few other possibilities) I’m going with an Rx reductionist approach and just taking what I have left. My life had juuuuuust started to become dr. appointment time based, and I made a decision long ago that I didn’t want that to be me. It’s a nice feeling to just take what I have left and go with it (I’m extremely active but privately - I don’t like to be around crowds). No more new meds, if there’s ca, no chemo or surgery. All on paper and the entire family is aware and on board. It’s a relief.
Respect your take and at 75, I am just beginning to think along the same lines. But at 60, hell, I was till young! I can't believe you see yourself as a "codger!" I was working, had the most energy in my step class, lifting wgts like crazy and really enjoying life. I fully understand your premise especially with the difficulty of getting timely appts and upon arrival, they.just.don't.have.time to listen. It gets "old."
lol I feel u. Just going thru a particularly rough moment - have been dealing with a perforated colon for 9 months after surgery #62 over my lifetime. I’m doing my best tho and staying busier than ever! I’ll have surgery again in November to close the perf permanently and maybe my mindset will change.
Being a (female) old codger myself, I love the terminology. I also love your sense of humor and your approach to medicine and the practice thereof. Thank you!!
Ezetimibe side effects are very hard to differentiate from placebo and the drug works by inhibiting GI absorption of cholesterol so many who are opposed to statins are willing to trial ezetimibe.
Thanks for your views on statins for old codgers. I'm doing research for a book on polypharmacy and prescription medication in later life. I've interviewed let's say the 'young old' , in their sixties, towards the start of their medication journey and found considerable reluctance to start taking a statin having been told that their cholesterol , plus QRISK3 score ( which many didn't fully understand) put them at heightened risk for a stroke or heart attack. Possible side effects, the perceived influence of Big Pharma, taking a pill for life - all given as reasons to decline. The compromise approach you suggest could convince, but I'm not sure many would have enough time, or the confidence, to have a full discussion in a snatched 10 minute GP consultation, and a request for a referral for a coronary artery calcium scan would likely be be refused on account of cost. Certainly worth considering though.
Good points and studies cited here. Thank you. I recall a study cited below (cohort) that suggested STOPPING statins in those over age 75 who are already taking them was associated with more major cardiovascular events than continuing them. So I rarely deprescribe statins in this age group without another reason. Does that sound about right?
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2786791
I would not use that cited observational study to guide your approach.
For primary prevention if the individual feels great and wants to continue taking the med then given the equipoise in this area it is reasonable to continue lipid lowering therapy. Many that I see who are >75 years want to stop medications due to concern about perceived or potential side effects, polypharmacy, etc. and if at or below average ASCVD risk for age (CAC helpful for knowing this with greater certainty) I think deprescribing make sense.
There are so many limitations to the observational data it is impossible to be confident that stopping statins caused increased risk of MACE and the authors of that JAMA have a lengthy paragraph summarizing them. In addition, this comment in response to the article points out that hip fractures, non cardiovascular death and frailty much more common in the group who stopped statins:
"In this recent article 1, Thompson et al. reported an association between statin discontinuation and major cardiovascular events (MACE) in a national cohort study of people aged ≥ 75 years (median age 79 years) on long-term statin therapy. We wish to comment on the main results of this study. First, in relative terms, the association between statin discontinuation and MACE both in primary prevention (PP) and in secondary prevention (SP) was moderate (risk ratio: RR: 1.37 and 1.22, respectively). More importantly, the association was not MACE-specific as people with statin discontinuation, in PP and SP, had higher risks of hip fracture (RR: 1.90 and 1.73, eTable 19) and of non-cardiovascular mortality (RR: 2.80 and 2.58, eTable 18). A strong association (RR ~ 2.0) between statin discontinuation and these later two non-statin dependent events is a clue that statin discontinuation is not the cause of poor health outcomes in the older population. Statin discontinuation might rather be the consequence of poor health status. Second, in absolute terms, the weighted rate difference between people with and without statin discontinuation was ten-times lower for MACE than for non-cardiovascular mortality (Table 3 vs. eTable 18) both in PP (9 vs. 87 ) and SP (13 vs. 133). We believe that such a high rate difference can not be statin-mediated. In case of statin discontinuation, the person number needed for one excess non-cardiovascular death vs. one excess MACE was thus ten-times lower both in PP (11 vs. 112 per 1.000 person-years) and in SP (8 vs. 77 per 1.000 person-years). Third, frailty could not be assessed using the study register data. In the discussion, the authors state the hypothesis that statin discontinuation is a marker of frailty and poorer health, and they mention that frailty may be a relevant confounder. We fully agree, and we believe that the reported E-value for 2 does not rule out a confounding by frailty, as frailty is proved to be strongly associated one the one hand with statin discontinuation 2, and on the other hand with MACE 3, hip fractures 4 and all-cause mortality 5.
Such observational and confounded data should not lead to causal interpretation. We agree that robust evidence from randomized controlled trails on statin discontinuation are deeply needed. Meanwhile, we suggest that physicians keep continuing statin discontinuation in older people."
I used the term overseasoned citizen. Mentally I function as a 13-year-old still trying to figure out life, the DMV claims that I'm 80, and my back feels like I'm 113.
I'm an old lady at age 77. Although I was encouraged to take statins with a total cholesterol of around 200, I always declined. No history of CVD and the only family history was my mother who had an acute MI in her late 80s after years of poorly controlled diabetes, so I just didn't see the need. About 2 years ago our family switched entirely to grass fed/finished meats. My last bloodwork showed that my total cholesterol has dropped 50 points with a corresponding drop in LDL. No idea whether there is a correlation there but it's really the only change that I have made. I enjoy your columns as a now retired cardiac/ER RN of over 40 years.
I reply as an official old codger: I just retired this year from full time cardiology practice at age 74. When people ask me why I retired, I say "because I'm old". In reality, I could not persuade my employer to remove me from the call schedule and give me a four day work week. Nor did I I want to go to another practice and start a new book of patients. Didn't really want to retire; still love the field and my patients! Just wanted more free time, and no more CYA calls in the middle of the night.
The PREVENTABLE trial and the STAREE trial are both looking at cognitive function, which is very interesting. As I lectured to house staff and gave CME talks to physicians, I found a belief that serum lipoproteins are somehow linked to cholesterol levels in brain membranes, thereby adversely affecting brain function. (Also, one of my colleagues told our PA that we shouldn't lower cholesterol too much so there is some left to make sex hormones.)
Patients often believe that statins worsen memory, and can find "experts" on the internet who agree.
I don't expect these trial to show a cognition benefit, but if they do, another huge indication for statins. But just showing no adverse effect will help.
p.s. I take a statin plus ezetimibe to keep my LDL about 70, despite no CAD history. I elected to do this without a calcium score, as long as I am free of side effects. I will never know what would have happened without treatment.
It's quite sad that what you experienced "I could not persuade my employer to remove me from the call schedule and give me a four day work week" is the norm with cardiology practices. I was very fortunate to be able to transition to a position with no call 4 years ago.
But it required an immense effort to get the people at the top of the organization to think outside the box and let me transition to an unorthodox part-time hybrid position.
Allowing more senior cardiologists to go to no call and part-time keeps extremely valuable , experienced and wise physicians in the work force. it also puts the physician in a space where can appreciate more the time spent with patients.
Your approach to primary prevention is one many cardiologists pursue as we have experienced over many years and in many patients how effective and safe it is.
I started asking for reduced call at age 62, a full decade earlier. Got nowhere.
How about we address who funded these studies number one? Number two, let’s make sure each of these studies takes the absolute risk reduction as the primary assessment with regard to risk/benefit ratios and not the relative risk reduction to stop fooling American consumers about minimal mortality benefits.
I agree one hundred percent. The pharmaceutical companies have way too much power and influence.
I'd love to read your take about the opposite end of the age spectrum in an article you title "Are you too young to consider primary prevention of ASCVD?"
I’m a 60 year old codger, and have decided after some drug reactions last year (statin vs corticosteroid vs a few other possibilities) I’m going with an Rx reductionist approach and just taking what I have left. My life had juuuuuust started to become dr. appointment time based, and I made a decision long ago that I didn’t want that to be me. It’s a nice feeling to just take what I have left and go with it (I’m extremely active but privately - I don’t like to be around crowds). No more new meds, if there’s ca, no chemo or surgery. All on paper and the entire family is aware and on board. It’s a relief.
Respect your take and at 75, I am just beginning to think along the same lines. But at 60, hell, I was till young! I can't believe you see yourself as a "codger!" I was working, had the most energy in my step class, lifting wgts like crazy and really enjoying life. I fully understand your premise especially with the difficulty of getting timely appts and upon arrival, they.just.don't.have.time to listen. It gets "old."
lol I feel u. Just going thru a particularly rough moment - have been dealing with a perforated colon for 9 months after surgery #62 over my lifetime. I’m doing my best tho and staying busier than ever! I’ll have surgery again in November to close the perf permanently and maybe my mindset will change.
Check out the above article!
https://www.linkedin.com/pulse/going-beyond-blood-biomarkers-optimize-cholesterol-production-kumar-hilwc?utm_source=share&utm_medium=member_ios&utm_campaign=share_via
Being a (female) old codger myself, I love the terminology. I also love your sense of humor and your approach to medicine and the practice thereof. Thank you!!
I'm quite relieved to heard that old codger doesn't offend you!
Thank you from the bottom of my old codger left ventricle.
Does ezetemibe have a more favorable risk profile than statins? If you’re willing to take Zetia, what’s the issues with taking a statin?
They both are very safe with minimal side effects.
Statins suffer from a strong nocebo effect (https://theskepticalcardiologist.com/2017/08/20/do-statins-cause-memory-loss-the-science-the-media-the-statin-denialist-cult-and-the-nocebo-effect/) and many individuals based on anecdotes or negative information on the internet have become unwilling to take them. I'm updating that my nocebo post now and will include the SAMSON trial which showed that 90% of statin side effects appear due to the nocebo effect.
Ezetimibe side effects are very hard to differentiate from placebo and the drug works by inhibiting GI absorption of cholesterol so many who are opposed to statins are willing to trial ezetimibe.