Primary prevention with statins for older adults

Primary prevention remains important for adults over 65 years because significant cardiovascular morbidity after an initial event. Up to one third have a further stroke or MI or die within three years. Current guidance on lipid management in older adults is inconsistent: the National Institute for Health and Care Excellence (NICE) recommends statins for primary prevention up to age 84, the European Society of Cardiology recommends treatment to age 65, and the American Heart Association (AHA) up to age 75. For those with type 2 diabetes, NICE recommends statin prescription guided by a CVD risk calculation, whereas the AHA recommends statins without risk calculation.

In a large retrospective cohort study of patients aged 75 or more, Ramos and colleagues [Ref] found no reduction in CVD (a composite of coronary heart disease and stroke) in those without diabetes using statin treatment for primary prevention [Ref]. However, there was a lower risk of CVD in those aged 75 or more with diabetes, at least up to age 85, after which the effects of statins on primary prevention of CVD attenuated. The authors did not find an increased risk of myopathy, liver toxicity, or type 2 diabetes mellitus associated with statin use in older adults. Concerns about statins and cognition have previously been expressed7 but were not recorded in this study.

As the editorial in the BMJ concludes [Ref], observational data have shown that researchers and patients having differing views on the relative importance of morbidity and mortality. Patients aged 65 or older prioritised reductions in myocardial infarction and stroke over avoiding death, in contrast with researchers and those younger than 65. Therefore, if in the process of shared decision making, older patients express a preference for extending longevity, then current evidence supporting statins for primary prevention remains limited. A patient preference for reduction in myocardial infarction or stroke, however, might help to tilt the balance in favour of statin prescription, but the absolute risk reduction and number needed to treat to prevent a CVD event in older patients remains uncertain.

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