Reviewed by Dr. Jake Hutto
Han, Benjamin H., et al. JAMA Internal Medicine (2017)

SUMMARY
Statins for primary atherosclerotic cardiovascular prevention reduce cardiovascular events and morbidity, but there is not a clear consensus of data supporting the use of statins for primary cardiovascular prevention in adults over the age of 75. This article is a post-hoc secondary analysis of participants in the Lipid Lowering Trial (LLT) component of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT-LLT) that took place from 1994-2002. The authors evaluated statin treatment in 2867 adults aged 65 years and older with hypertension and without known atherosclerotic cardiovascular disease. 1467 individuals were randomized to treatment with pravastatin sodium 40mg daily, and 1400 individuals were randomized to usual care (UC). Treatment in the UC group was at the discretion of the patient’s primary care physician. The primary outcome was all-cause mortality, and secondary outcomes included cause-specific mortality and nonfatal myocardial infarction or fatal coronary heart disease combined. Hazard ratios for all-cause mortality in the pravastatin group vs. the UC group were 1.18 (95% CI 0.97 – 1.42, P = 0.09) for all adults 65 years and older, 1.08 (95% CI 0.85 – 1.37, P = 0.55) for adults aged 65 – 74 years, and 1.34 (95% CI 0.98 – 1.84, P = 0.07) for adults aged 75 years or older. Hazard ratios for coronary heart disease events, stroke, heart failure, and cancer rates were also not significantly different among treatment groups. Overall, there was no significant benefit with pravastatin treatment for primary cardiovascular prevention in adults over 65 with hypertension, as well as a statistically non-significant trend towards increased all-cause-mortality with pravastatin treatment in individuals over the age of 75.

COMMENTARY
We see numerous older adults in clinic that are on many medications, and this article highlights an opportunity to discuss with our patients the risks and benefits of starting statin therapy beyond the age of 75 years. Studies have shown that elevated lipid levels are less predictive of overall cardiovascular risk as patients age, and have also shown an increased mortality rate associated with low lipid levels in the oldest age groups. Though evidence is unclear, there are also studies that show adults over the age of 65 are at higher risk for statin-induced myopathy and musculoskeletal problems. They also have a five times higher risk of hospitalization for rhabdomyolysis compared to adults under the age of 65. Furthermore, there is questionable evidence regarding the use of statins in elderly individuals and negative effects on cognition. Some studies showed that statin treatment did not lead to cognitive decline or incidental dementia, but these studies acknowledge that they included only a very small number of patients over the age of 80. The HOPE (Heart Outcomes Prevention Evaluation) randomized elderly individuals to rosuvastatin treatment or placebo and showed no statistically significant difference in death from any cause between the two groups (5.3% vs 5.6%, respectively). When individuals were stratified by age to compare all-cause mortality in individuals 65 years or younger with those older than 65 years, no benefits in all-cause mortality were noted between the two groups.

While this analysis of the ALLHAT-LLT trial does not address continued statin therapy in elderly patients with known atherosclerotic coronary artery disease or treatment with a high intensity statin, it does highlight an opportunity for us to avoid adding to polypharmacy by discussing the risks and benefits of starting statins for primary prevention in older adults.

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