Lown Right Care
Reducing Overuse and Underuse
Overuse of Statins in Older Adults
Am Fam Physician. 2019 Dec 15;100(12):742-743.
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Mr. G is an 83-year-old man who lives alone with some assistance from family members. He has well-controlled hypertension, hyperlipidemia, and arthritis. His maximum low-density lipoprotein (LDL) cholesterol level is around 135 mg per dL (3.50 mmol per L). He uses a walker and has fallen several times in the past year, sustaining a wrist fracture. He had a coronary stent placed 15 years ago for asymptomatic coronary artery disease (CAD) that was detected after an exercise stress test. He has visited a cardiologist since the stent placement and is taking 80 mg of atorvastatin (Lipitor) per day to reduce his LDL cholesterol to below 80 mg per dL (2.07 mmol per L). His family physician is uncertain if Mr. G benefits from the high-dose statin because his primary two symptoms are fatigue and muscle weakness. Mr. G's cardiologist feels that the dose is appropriate, and that his symptoms are not related to the statin. Mr. G's family physician plans to keep him on a statin indefinitely, because statins are required for anyone older than 21 years with a diagnosis of CAD according to the Centers for Medicare and Medicaid Services quality indicator #438.
The 2018 American College of Cardiology/American Heart Association guideline states that it may be reasonable to initiate or continue moderate- to high-dose statin therapy for secondary prevention and initiate moderate-dose statin therapy for primary prevention in people older than 75 years if they have an LDL cholesterol level of 70 to 189 mg per dL (1.81 to 4.90 mmol per L). For primary prevention, this means that 18 million older adults could be eligible for a statin.1 However, there are few data about the impact of statins on longevity, cardiac outcomes, and muscle strength in adults older than 75 years.
PRIMARY PREVENTION IN PATIENTS WITHOUT RISK FACTORS FOR CAD
No study has shown an impact of statins on cardiovascular outcomes among older adults without preexisting CAD or significant risk factors. The U.S. Preventive Services Task Force guideline states that current evidence is insufficient to assess the balance of benefits and harms of statins in people older than 75 years who have no history of stroke or heart attack.2 For people 65 to 75 years of age with one or more risk factors, the U.S. Preventive Services Task Force recommends that clinicians selectively prescribe statins for those with at least one risk factor and a 7.5% to 10% risk of a cardiovascular event in 10 years.2 The ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial) evaluated the use of pravastatin (Pravachol) for primary prevention in adults older than 65 years who had high cholesterol.3 The study found no improvement in CAD or mortality in the pravastatin arm despite decreases in LDL cholesterol. There was also a trend toward higher mortality with statins in those older than 75 years. Subgroup analyses of people older than 75 in other studies have shown variable benefits of statins on cardiovascular outcomes and no reductions in mortality.4
Many older people are prescribed statins
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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.
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