Coronary heart disease (CHD) is the leading cause of death in patients older than 65 years. Carlsson and colleagues summarize current studies about treatment of dyslipidemia in elderly patients.
Plateaus in total cholesterol (TC) and low-density lipoprotein (LDL) cholesterol levels are reached in men and women around ages 50 and 60 years, respectively. The Framingham Heart Study revealed that an independent predictor of future myocardial infarction and CHD death was a TC level greater than 306 mg per dL (7.90 mmol per L) in patients older than 65 years without CHD. In patients more than 85 years of age, however, there was no association between CHD death and TC. There are few studies about dyslipidemias in patients older than 85 years, so evidence-based recommendations are limited to patients between 65 and 85 years of age.
Lipid-lowering strategies include exercise, diet and lipid-lowering medications (see accompanying table). Exercise has been shown to improve lipid profiles, although when the regimen is stopped, lipid levels return to pre-exercise–regimen levels. A low-fat, low-cholesterol diet (step I or step II), as recommended by the National Cholesterol Education Program (NCEP), has been shown to reduce TC levels by as much as 20 percent. In particular, saturated fatty acids and dietary cholesterol should be avoided. The so-called Mediterranean diet (with increased intake of fruits, vegetables, olive oil and red wine) may have a variety of cardioprotective effects.
|Exercise||0 to 6||0 to 19||1 to 21||3 to 8|
|Diet||5 to 20||−4 to −22||60 to +5||6 to 21|
|Lovastatin (20 to 40 mg)||17 to 20||7 to 9||4 to 10||24 to 28|
|Pravastatin (10 to 40 mg)||20 to 22||5 to 11||8 to 17||25 to 32|
|Simvastatin (20 to 40 mg)||26||7||14||36|
|Hormone replacement therapy||2 to 14||6 to 21||15 to 42||13 to 24|
*—HDL changes are elevations unless otherwise noted.
TC = total cholesterol; HDL = high-density lipoproteins; TG = triglycerides; LDL = low-density lipoproteins.
Reprinted with permission from Carlsson CM, Carnes M, McBride PE, Stein JH. Managing dyslipidemia in older adults. J Am Geriatr Soc 1999;47:1461.
Of all of the lipid-lowering medications, 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (also known as statins) have been shown to be effective and well tolerated in older patients. A variety of studies, including the Scandinavian Simvastatin Survival Study (4S) and the Cholesterol
Reduction in Seniors Program (CRISP), showed that LDL cholesterol, TC and triglyceride levels were reduced, and high-density lipoprotein (HDL) cholesterol levels were increased in patients taking statins. It is not clear that bile acid sequestrants, niacin and fibric acid derivatives are as effective in older patients. In addition, there has not been a randomized controlled trial that evaluates lipid-lowering agents' ability to decrease the number of CHD events in the elderly. Lipid-lowering in elderly patients without CHD (primary prevention) has not been well studied. However, there is a clear benefit to lipid reduction in elderly patients with CHD (secondary prevention). The benefits include reduced total mortality, reduced number of coronary events, reduced need for coronary revascularization procedures and a reduced stroke rate.
Evaluating subgroups from several studies that collectively enrolled more than 7,000 elderly patients shows that only 10 to 24 patients need to be treated to prevent one major CHD event in a five- to six-year time frame. The authors recommend obtaining a screening fasting lipid profile in patients up to 85 years of age (unless their life expectancy is less than two years). Patients with abnormal lipid profiles should follow an NCEP step I or step II diet and an exercise program. If no improvements have occurred within four weeks, pharmacologic therapy should be considered, especially in patients with two or more CHD risk factors. These patients should be started on an HMG-CoA reductase inhibitor (statin) unless their triglyceride level is greater than 350 mg per dL (3.95 mmol per L). Hormone replacement therapy should be discussed with postmenopausal women.
The authors conclude that CHD events are increased by elevated LDL cholesterol and TC levels, and that cardiovascular mortality is decreased by high HDL cholesterol levels in elderly patients up to 85 years of age. Diet, exercise and pharmacotherapy can all be recommended to patients at high risk of cardiac events. Statins have a safe side effect profile in patients up to 85 years of age; other lipid-lowering agents need to be studied in more depth.