Role of Statin Therapy in Primary Prevention of Cardiovascular Disease in Elderly Patients

Curbside Consult Optimizing Statin Therapy in the Elderly: A Personalized Approach to Cardiovascular Disease Prevention

Statins (3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors) play a vital role in managing and preventing cardiovascular disease, particularly in elderly populations who face elevated risks for atherosclerosis and related conditions. This review delves into the mechanisms of statin action, emphasizing their impact on low-density lipoprotein cholesterol levels, anti-inflammatory properties, and potential genetic factors influencing efficacy and drug tolerability. Consideration is given to statin intolerance and management strategies, drug interactions, and guidelines for primary and secondary prevention of cardiovascular events. Patient-centered care and shared decision-making are highlighted as essential for effective therapy in elderly patients. This review also addresses the importance of personalized approaches in the context of genetic markers such as SLCO1B1 polymorphisms, optimizing patient outcomes and minimizing adverse effects. Finally, emerging areas of research are discussed, underscoring the need for further studies on the cognitive impact of statins and newer lipid-lowering agents. This analysis serves to inform clinical practice by balancing statins' cardiovascular benefits against potential risks, aiming for a tailored approach in managing elderly patients with cardiovascular concerns.

Mesenchymal stem cell therapy in atherosclerosis: A bibliometric and visual analysis

BACKGROUND

Mesenchymal stem cells (MSCs) are capable of self-renewal and differentiation, and extensive studies have demonstrated their therapeutic potential in atherosclerosis (AS).

AIM

To conduct a bibliometric analysis of studies on the use of MSC therapy for AS over the past two decades, assess key trends and provide insights for future research directions.

METHODS

We systematically searched the Web of Science Core Collection database for articles published between 1999 and 2023, yielding a total of 556 articles. Visual representation and bibliometric analysis of information and trends were facilitated using CiteSpace, the R package 'bibliometrix' and VOSviewer.

RESULTS

The analyzed articles were predominantly from 52 countries/regions, with prominent contributions from China and the United States. A cohort of 3057 authors contributed to these publications, with the works of Libby P distinguished by their influence and citation count. Int J Mol Sci has emerged as the journal with the highest publication volume, prominently disseminating influential papers and identifying citation outbreaks. Furthermore, our analysis identified current research hotspots within the field, focusing on vascular progenitor cells, inflammatory mechanisms, and extracellular vesicles. Emerging research frontiers, such as extracellular vesicles and oxidative stress, have been highlighted as areas of burgeoning interest. Finally, we offer perspectives on the status of research and future directions of MSC therapy in AS.

CONCLUSION

This comprehensive analysis provides valuable insights for advancing scientific research on MSC therapy for AS. By elucidating pivotal trends and research directions, this study aimed to foster innovation and promote the progress of disciplines in this field, thereby contributing to advancing scientific knowledge and clinical practice.

Discontinuation versus continuation of statins: A systematic review

BACKGROUND

Clinicians and patients often face a decision to continue or discontinue statins. We examined the impact of discontinuation of statins compared with continuation on clinical outcomes (all-cause mortality, cardiovascular [CV] mortality, CV events, and quality of life).

METHODS

We conducted a systematic review. Randomized controlled trials (RCTs), cohort studies, case-control studies, and quasi-randomized studies among people ≥18 years were eligible. We searched MEDLINE, Embase, and Cochrane Central Registry (inception to August 2023). Two independent reviewers performed screening and extracted data. Quality assessment was performed by one author and verified by another. We summarized results narratively, performed meta-analysis for a subset of studies, and used GRADE to assess certainty of evidence. We summarized findings in the subgroup of persons ≥75 years.

RESULTS

We retrieved 8369 titles/abstracts; 37 reports from 36 studies were eligible. This comprised 35 non-randomized studies (n = 1,708,684) and 1 RCT (n = 381). The 1 RCT was conducted among persons with life expectancy <1 year and showed there is probably no difference in 60-day mortality (risk difference = 3.5%, 90% CI -3.5 to 10.5) for statin discontinuation compared with continuation. Non-randomized studies varied in terms of population and setting, but consistently suggested that statin discontinuation might be associated with a relative increased risk of mortality (hazard ratio (HR) 1.92, 95% CI 1.52 to 2.44, nine studies), CV mortality (HR 1.63, 95% CI 1.27 to 2.10, five reports), and CV events (HR 1.31, 95% CI 1.23 to 1.39, eight reports). Findings in people ≥75 years were consistent with main results. There was a high degree of uncertainty in findings from non-randomized studies due to methodological limitations.

CONCLUSIONS

Statin discontinuation does not appear to affect short-term mortality near end-of-life based on one RCT. Outside of this population, findings from non-randomized studies consistently suggested statin discontinuation may be associated with worse outcomes, though this is uncertain.

Statin treatment for primary and secondary prevention in elderly patients-a cross-sectional study in Stockholm, Sweden

BACKGROUND

Age is a major risk factor for atherosclerotic cardiovascular disease (CVD) and death, but there has been a debate about benefit-risk of statin treatment in the elderly with limited evidence on benefits for primary prevention, while there is strong evidence for its use in secondary prevention.

AIM

The aim of this study was to provide an overview of statin utilization in primary and secondary prevention for patients 75-84 years and ≥ 85 years in the Swedish capital Region Stockholm in 2019.

METHODS

This is a cross-sectional study based on the regional healthcare database VAL containing all diagnoses and dispensed prescription drugs for all 174,950 inhabitants ≥ 75 years old in the Stockholm Region. Prevalence and incidence were analyzed by sex, age, cardiovascular risk, substance, and the intensity of treatment.

RESULTS

A total of 35% of all individuals above the age of 75 in the region were treated with statins in 2019. The overall incidence in this age group was 31 patients per 1000 inhabitants. Men, individuals 75-84 compared to ≥ 85 years of age, and those with higher cardiovascular risk were treated to a greater extent. Simvastatin was used primarily by prevalent users and atorvastatin by incident users. The majority was treated with moderate-intensity dosages and fewer women received high intensity treatment.

CONCLUSIONS

Statins are widely prescribed in the elderly. Physicians seem to consider individual cardiovascular risk when deciding to initiate statin treatment for elderly patients, but here may still be some undertreatment among high-risk patients (especially women and elderly 85 + years) and some overtreatment among patients with low-risk for CVD.

Cholesterol Lowering in Older Adults: Should We Wait for Further Evidence?

PURPOSE OF REVIEW

Current guidelines for primary and secondary prevention of cardiovascular events in adults up to age 75 years are well-established. However, recommendations for lipid-lowering therapies (LLT), particularly for primary prevention, are inconclusive after age 75. In this review, we focus on adults ≥ 75 years to assess low-density lipoprotein-cholesterol (LDL-C) as a marker for predicting atherosclerotic cardiovascular disease (ASCVD) risk, review risk assessment tools, highlight guidelines for LLT, and discuss benefits, risks, and deprescribing strategies.

RECENT FINDINGS

The relationship between LDL-C and all-cause mortality and cardiovascular outcomes in older adults is complex and confounded. Current ASCVD risk estimators heavily depend on age and lack geriatric-specific variables. Emerging tools may reclassify individuals based on biologic rather than chronologic age, with coronary artery calcium scores gaining popularity. After initiating LLT for primary or secondary prevention, target LDL-C levels for older adults are lacking, and non-statin therapy thresholds remain unknown, relying on evidence from younger populations. Shared decision-making is crucial, considering therapy's time to benefit, life expectancy, adverse events, and geriatric syndromes. Deprescribing is recommended in end-of-life care but remains unclear in fit or frail older adults. After an ASCVD event, LLT is appropriate for most older adults, and deprescribing can be considered for those approaching the last months of life. Ongoing trials will guide statin prescription and deprescribing among older adults free of ASCVD. In the interim, for adults ≥ 75 years without a limited life expectancy who are free of ASCVD, an LLT approach that includes both lifestyle and medications, specifically statins, may be considered after shared decision-making.

Patterns of Statin Therapy Use and Associated Outcomes in Older Veterans Across Kidney Function

BACKGROUND

Despite significant morbidity and mortality related to atherosclerotic cardiovascular disease, to date, most major clinical trials studying the effects of statin therapy have excluded older adults. The objective of this analysis was to evaluate the effect of initiating statin therapy on incident dementia and mortality among individuals 75 years of age or older across the complete spectrum of kidney function.

METHODS

We conducted a retrospective cohort study of 640,191 VA health system patients who turned 75 years of age between 2000 and 2018. Patients on statin therapy received the medication for an average of 6.3 years (standard deviation 4.6 years). The primary outcome of interest included incident dementia diagnosis during the study period. The secondary outcome was all-cause mortality. Cox proportional hazard analysis was used to evaluate the adjusted association of statin initiation with these outcomes.

RESULTS

There was a higher rate of incident dementia in the No Statin group (4.7%) vs the Statin group (3.2%). Additionally, we observed a 22% all-cause mortality benefit associated with statin therapy. We did not observe a treatment effect with respect to primary or secondary outcomes across varying levels of kidney function.

CONCLUSION

This large cohort study did not reveal an association between the initiation of statin therapy and incident dementia. A survival benefit was seen in statin users compared with nonusers. Prospective studies in more diverse populations including older adults will be needed to verify these findings.

A Look at Primary and Secondary Prevention in the Elderly: The Two Sides of the Same Coin

The global population is experiencing an aging trend; however, this increased longevity is not necessarily accompanied by improved health in older age. A significant consequence of this demographic shift is the rising prevalence of multiple chronic illnesses, posing challenges to healthcare systems worldwide. Aging is a major risk factor for multimorbidity, which marks a progressive decline in resilience and a dysregulation of multisystem homeostasis. Cardiovascular risk factors, along with aging and comorbidities, play a critical role in the development of heart disease. Among comorbidities, age itself stands out as one of the most significant risk factors for cardiovascular disease, with its prevalence and incidence notably increasing in the elderly population. However, elderly individuals, especially those who are frail and have multiple comorbidities, are under-represented in primary and secondary prevention trials aimed at addressing traditional cardiovascular risk factors, such as hypercholesterolemia, diabetes mellitus, and hypertension. There are concerns regarding the optimal intensity of treatment, taking into account tolerability and the risk of drug interactions. Additionally, uncertainty persists regarding therapeutic targets across different age groups. This article provides an overview of the relationship between aging and cardiovascular disease, highlighting various cardiovascular prevention issues in the elderly population.

Navigating Lipodystrophy: Insights from Laminopathies and Beyond

Recent research into laminopathic lipodystrophies-rare genetic disorders caused by mutations in the LMNA gene-has greatly expanded our knowledge of their complex pathology and metabolic implications. These disorders, including Hutchinson-Gilford progeria syndrome (HGPS), Mandibuloacral Dysplasia (MAD), and Familial Partial Lipodystrophy (FPLD), serve as crucial models for studying accelerated aging and metabolic dysfunction, enhancing our understanding of the cellular and molecular mechanisms involved. Research on laminopathies has highlighted how LMNA mutations disrupt adipose tissue function and metabolic regulation, leading to altered fat distribution and metabolic pathway dysfunctions. Such insights improve our understanding of the pathophysiological interactions between genetic anomalies and metabolic processes. This review merges current knowledge on the phenotypic classifications of these diseases and their associated metabolic complications, such as insulin resistance, hypertriglyceridemia, hepatic steatosis, and metabolic syndrome, all of which elevate the risk of cardiovascular disease, stroke, and diabetes. Additionally, a range of published therapeutic strategies, including gene editing, antisense oligonucleotides, and novel pharmacological interventions aimed at addressing defective adipocyte differentiation and lipid metabolism, will be explored. These therapies target the core dysfunctional lamin A protein, aiming to mitigate symptoms and provide a foundation for addressing similar metabolic and genetic disorders.

Benefits and Risks Associated With Statin Therapy for Primary Prevention in Old and Very Old Adults : Real-World Evidence From a Target Trial Emulation Study

BACKGROUND

There is little consensus on using statins for primary prevention of cardiovascular diseases (CVDs) and all-cause mortality in adults aged 75 years or older due to the underrepresentation of this population in randomized controlled trials.

OBJECTIVE

To investigate the benefits and risks of using statins for primary prevention in old (aged 75 to 84 years) and very old (aged ≥85 years) adults.

DESIGN

Sequential target trial emulation comparing matched cohorts initiating versus not initiating statin therapy.

SETTING

Territory-wide public electronic medical records in Hong Kong.

PARTICIPANTS

Persons aged 75 years or older who met indications for statin initiation from January 2008 to December 2015 were included. Participants with preexisting diagnosed CVDs at baseline, such as coronary heart disease (CHD), were excluded from the analysis. Among 69 981 eligible persons aged 75 to 84 years and 14 555 persons aged 85 years or older, 41 884 and 9457 had history of CHD equivalents (for example, diabetes) in the respective age groups.

INTERVENTION

Initiation of statin therapy.

MEASUREMENTS

Incidence of major CVDs (stroke, myocardial infarction, or heart failure), all-cause mortality, and major adverse events (myopathies and liver dysfunction).

RESULTS

Of 42 680 matched person-trials aged 75 to 84 years and 5390 matched person-trials aged 85 years or older (average follow-up, 5.3 years), 9676 and 1600 of them developed CVDs in each age group, respectively. Risk reduction for overall CVD incidence was found for initiating statin therapy in adults aged 75 to 84 years (5-year standardized risk reduction, 1.20% [95% CI, 0.57% to 1.82%] in the intention-to-treat [ITT] analysis; 5.00% [CI, 1.11% to 8.89%] in the per protocol [PP] analysis) and in those aged 85 years or older (ITT: 4.44% [CI, 1.40% to 7.48%]; PP: 12.50% [CI, 4.33% to 20.66%]). No significantly increased risks for myopathies and liver dysfunction were found in both age groups.

LIMITATION

Unmeasured confounders, such as lifestyle factors of diet and physical activity, may exist.

CONCLUSION

Reduction for CVDs after statin therapy were seen in patients aged 75 years or older without increasing risks for severe adverse effects. Of note, the benefits and safety of statin therapy were consistently found in adults aged 85 years or older.

PRIMARY FUNDING SOURCE

Health Bureau, the Government of Hong Kong Special Administrative Region, China, and National Natural Science Foundation of China.

LY86 facilitates ox-LDL-induced lipid accumulation in macrophages by upregulating SREBP2/HMGCR expression

LY86, also known as MD1, has been implicated in various pathophysiological processes including inflammation, obesity, insulin resistance, and immunoregulation. However, the role of LY86 in cholesterol metabolism remains incompletely understood. Several studies have reported significant up-regulation of LY86 mRNA in atherosclerosis; nevertheless, the regulatory mechanism by which LY86 is involved in this disease remains unclear. In this study, we aimed to investigate whether LY86 affects ox-LDL-induced lipid accumulation in macrophages. Firstly, we confirmed that LY86 is indeed involved in the process of atherosclerosis and found high expression levels of LY86 in human atherosclerotic plaque tissue. Furthermore, our findings suggest that LY86 may mediate intracellular lipid accumulation induced by ox-LDL through the SREBP2/HMGCR pathway. This mechanism could be associated with increased cholesterol synthesis resulting from enhanced endoplasmic reticulum stress response.

Statin-Associated Liver Dysfunction and Muscle Injury: epidemiology, Mechanisms, and Management Strategies

Surveillance of drug safety is an important aspect in the routine medical care. Adverse events caused by real-world drug utilization has become one of the leading causes of death and an urgent issue in the field of toxicology. Cardiovascular disease is now the leading cause of fatal diseases in most countries, especially in the elderly population who often suffer from multiple diseases and need long-term multidrug therapy. Among which, statins have been widely used to lower bad cholesterol and regress coronary plaque mainly in patients with hyperlipidemia and atherosclerotic cardiovascular diseases (ASCVD). Although the real-world benefits of statins are significant, different degrees and types of adverse drug reactions (ADR) such as liver dysfunction and muscle injury, have a great impact on the original treatment regimens as well as the quality of life. This review describes the epidemiology, mechanisms, early identification and post-intervention of statin-associated liver dysfunction and muscle injury based on the updated clinical evidence. It provides systematic and comprehensive guidance and necessary supplement for the clinical safety of statin use in cardiovascular diseases.

Use of Statins in Heart Failure with Preserved Ejection Fraction: Current Evidence and Perspectives

Systemic inflammation and coronary microvascular endothelial dysfunction are essential pathophysiological factors in heart failure (HF) with preserved ejection fraction (HFpEF) that support the use of statins. The pleiotropic properties of statins, such as anti-inflammatory, antihypertrophic, antifibrotic, and antioxidant effects, are generally accepted and may be beneficial in HF, especially in HFpEF. Numerous observational clinical trials have consistently shown a beneficial prognostic effect of statins in patients with HFpEF, while the results of two larger trials in patients with HFrEF have been controversial. Such differences may be related to a more pronounced impact of the pleiotropic properties of statins on the pathophysiology of HFpEF and pro-inflammatory comorbidities (arterial hypertension, diabetes mellitus, obesity, chronic kidney disease) that are more common in HFpEF. This review discusses the potential mechanisms of statin action that may be beneficial for patients with HFpEF, as well as clinical trials that have evaluated the statin effects on left ventricular diastolic function and clinical outcomes in patients with HFpEF.

Polypharmacy and Deprescribing in Older Adults

Older adults commonly end up on many medications. Deprescribing is an important part of individualizing care for older adults. It is an opportunity to discuss treatment options and revisit medications that may not have been reassessed in many years. A large evidence base exists in the field, suggesting that deprescribing is feasible and safe, though questions remain about the potential clinical benefits. Deprescribing research faces a myriad of challenges, such as identifying and employing the optimal outcome measures. Further, there is uncertainty about which deprescribing approaches are likely to be most effective and in what contexts. Evidence on barriers and facilitators to deprescribing has underscored how deprescribing in routine clinical practice can be complex and challenging. Thus, finding practical, sustainable ways to implement deprescribing is a priority for future research in the field.

Preventive cardiology for the aging population: how can we better design clinical trials of statins?

INTRODUCTION

Older adults form a fast-increasing proportion of the world population. However, gains in increasing quantity of life have not been accompanied by similar gains in quality of life. Older people frequently experience frailty, memory problems, and chronic diseases including cardiovascular disease (CVD) and neurodegenerative diseases. Recent trials have demonstrated the efficacy of anti-hypertensive therapy in older populations but failed to show benefits for aspirin.

AREA COVERED

Statins clearly reduce CVD events in middle-aged populations. There seems to be evidence that the effect is similar in primary prevention older populations based on meta-analyses mainly from sub-groups in large trials, but this becomes less clear with increasing age. However, given differences in drug metabolism and possibly efficacy, competing co-morbidities, their effects on mortality, disability, and dementia in this age group remain to be determined.

EXPERT OPINION

Two large trials are now underway to clarify the role of statin therapy in people aged over 70 years using endpoints of mortality, disability, and neurocognitive endpoints as well as standard cardiovascular disease outcomes. They may provide also provide more evidence on how to approach the over 80 year age group.

Don't Judge a Book by Its Cover: The Role of Statins in Liver Cancer

Statins, which are inhibitors of 3-hydroxy-3-methyl-glutaryl-coenzyme A (HMG-CoA) reductase, are an effective pharmacological tool for lowering blood cholesterol levels. This property makes statins one of the most popular drugs used primarily to prevent cardiovascular diseases, where hyperlipidemia is a significant risk factor that increases mortality. Nevertheless, studies conducted mainly in the last decade have shown that statins might prevent and treat liver cancer, one of the leading causes of cancer-related mortality worldwide. This narrative review summarizes the scientific achievements to date regarding the role of statins in liver tumors. Molecular biology tools have revealed that cell growth and proliferation can be inhibited by statins, which further inhibit angiogenesis. Clinical studies, supported by meta-analysis, confirm that statins are highly effective in preventing and treating hepatocellular carcinoma and cholangiocarcinoma. However, this effect may depend on the statin's type and dose, and more clinical trials are required to evaluate clinical effects. Moreover, their potential hepatotoxicity is a significant caveat for using statins in clinical practice. Nevertheless, this group of drugs, initially developed to prevent cardiovascular diseases, is now a key candidate in hepato-oncology patient management. The description of new drug-statin-like structures, e.g., with low toxicity to liver cells, may bring another clinically significant improvement to current cancer therapies.

Efficacy and safety of berberine for several cardiovascular diseases: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Berberine has been widely used for the adjuvant therapy of several cardiovascular diseases (CVDs). However, evidence for its efficacy remains controversial.

PURPOSE

This study aimed to evaluate the efficacy and safety of berberine in CVDs.

STUDY DESIGN

A systematic review and meta-analysis of randomized controlled trials (RCTs).

METHODS

We searched ten electronic databases for articles from inception to December 23, 2022. RCTs comparing berberine alone or combined with statins versus statins or routine for CVDs were included. Meta-analysis was performed according to the Cochrane Handbook.

RESULTS

Forty-four RCTs were included with 4606 patients. There were no differences between berberine alone and routine or statins in improving total cholesterol (TC) (SMD, 0.43; 95% CI, -0.39 to 1.24; p = 0.30; I² = 95%), triglyceride (TG) (SMD, -0.14; 95% CI, -0.49 to 0.21; p = 0.44; I² = 76%), low-density lipoprotein cholesterol (LDL-C) (SMD, 0.69; 95% CI, -0.23 to 1.60; p = 0.14; I² = 96%), high-density lipoprotein cholesterol (HDL-C) (SMD, 0.55; 95% CI, -0.48 to 1.57; p = 0.30; I² = 96%), and Crouse score levels. Berberine alone significantly reduced National Institute of Health Stroke Scale (NIHSS) score, high-sensitivity C-reactive protein (hs-CRP), interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), and intima-media thickness (IMT) levels than routine therapy. Berberine plus statins significantly reduced TC, TG, LDL-C, NIHSS score, hs-CRP, TNF-α, IMT, Crouse score, and number of unstable plaques levels than routine or statins. However, no differences were found between groups in improving HDL-C and IL-6 levels. There were no significant differences between groups in the incidence of adverse reactions.

CONCLUSION

This study suggests that berberine may be a promising alternative for CVDs with no serious adverse reactions. However, our results may be limited by the quality of existing research. High-quality RCTs are needed to provide more convinced evidence.

Effect of Ginkgo biloba extract on pharmacology and pharmacokinetics of atorvastatin in rats with hyperlipidaemia

Ginkgo biloba extract (GBE) is a common dietary supplement used by people with dyslipidaemia worldwide to reduce the risk of cardiovascular disease. Many studies have found that GBE itself has a variety of pharmacological activities. However, the role of GBE as an adjunct to conventional therapy with chemical drugs remains controversial. Therefore, this study explored the additional benefits of GBE in the treatment of hyperlipidaemia with statins in terms of both pharmacodynamics and pharmacokinetics. A hyperlipidaemia model was established by feeding rats a high-fat diet for a long time. The animals were treated with atorvastatin only, GBE only, or a combination of atorvastatin and GBE. The results showed that statins combined with GBE could significantly improve the blood lipid parameters, reduce the liver fat content, and reduce the size of adipocytes in abdominal fat. The effect was superior to statin therapy alone. In addition, the combination has shown additional liver protection against possible pathological liver injury or statin-induced liver injury. A lipidomic study showed that GBE could regulate the abnormal lipid metabolism of the liver in hyperlipemia. When statins are combined with GBE, this callback effect introduced by GBE on endogenous metabolism has important implications for resistance to disease progression and statin resistance. Finally, in the presence of GBE, there was a significant increase in plasma statin exposure. These results all confirmed that GBE has incremental benefits as a dietary supplement of statin therapy for dyslipidaemia.

Review of Recent Laboratory and Experimental Data on Cardiotoxicity of Statins

Due to the fact that statins are among the most high-demand therapeutic agents used for the treatment and prevention of the most common cardiovascular diseases, a significant amount of research is focused on these drugs. As a result, the study and discovery of new effects in statin drugs continues. Research methods are constantly being improved in terms of their sensitivity and specificity, which leads to a change in ideas. In addition to the main lipid-lowering effect, statins have a number of additional effects, which can be conditionally divided into positive (pleiotropic) and negative (side effects). Moreover, information about many of the pleiotropic effects of statins is controversial and may subsequently change as new data become available. To a large extent, this is due to the introduction of new and the improvement of old methods of study: clinical, laboratory and morphological ones. Recent studies report the possibility of statins having potential cardiotoxic properties, which is expressed by an increase in the concentration of highly sensitive cardiac troponins, as well as various adverse changes in cardiac myocytes at the ultrastructural and molecular levels. This paper discusses possible mechanisms of statin cardiotoxicity. This narrative review is based on an analysis of publications in the Medline, PubMed, PubMed Central and Embase databases. The terms "statins", "troponin", "troponin I", "troponin T" in combination with "cardiotoxicity", "false positive", "mechanisms of increase", "pathophysiological mechanisms", "oxidative stress" and "cardiomyocyte apoptosis" were used to search publications.

Statins in High Cardiovascular Risk Patients: Do Comorbidities and Characteristics Matter?

Atherosclerotic cardiovascular disease (ASCVD) morbidity and mortality are decreasing in high-income countries, but ASCVD remains the leading cause of morbidity and mortality in high-income countries. Over the past few decades, major risk factors for ASCVD, including LDL cholesterol (LDL-C), have been identified. Statins are the drug of choice for patients at increased risk of ASCVD and remain one of the most commonly used and effective drugs for reducing LDL cholesterol and the risk of mortality and coronary artery disease in high-risk groups. Unfortunately, doctors tend to under-prescribe or under-dose these drugs, mostly out of fear of side effects. The latest guidelines emphasize that treatment intensity should increase with increasing cardiovascular risk and that the decision to initiate intervention remains a matter of individual consideration and shared decision-making. The purpose of this review was to analyze the indications for initiation or continuation of statin therapy in different categories of patient with high cardiovascular risk, considering their complexity and comorbidities in order to personalize treatment.

Investigation of Statin Medication Use in Elderly Patients with Cardiovascular Disease on Regular Physical Examination and the Relationship with Glucolipid Metabolism and Adverse Cardiovascular Prognosis

Our purpose of this study was to investigate the use of statins in elderly patients with cardiovascular diseases during regular physical examination and to analyze the relationship between statins and glucose and lipid metabolism and adverse cardiovascular prognosis. From January 2019 to December 2021, 2121 elderly patients with cardiovascular disease underwent regular physical examination as the study subjects to investigate the use and intensity of statins. The patients were divided into the dosing group (n = 1848) and the nondosing group (n = 273) according to whether they were taking statins or not. The cardiac function, glucose and lipid metabolism indexes, and cardiovascular adverse events were compared between the two groups. Statin use in elderly patients with cardiovascular disease was 87.13% (1848/2121). The intensity of statin use decreased with age (P < 0.05); the left ventricular ejection fraction (LVEF) was greater in the medicated group than in the nonmedicated group, and the left ventricular end-diastolic internal diameter (LVDd) and left ventricular end-systolic internal diameter (LVDs) were smaller than in the nonmedicated group (P < 0.05). The total cholesterol (TC), triglyceride (TG), low-density lipoprotein cholesterol (LDL-C), and fasting blood glucose (FBG) levels were lower in the medicated group than in the nonmedicated group, the high-density lipoprotein cholesterol (HDL-C) levels were higher than in the nonmedicated group, and the glycated hemoglobin (HbA1c) values were lower than in the nonmedicated group (P < 0.05). The overall incidence of cardiovascular adverse events in the medicated group was lower than that in the nonmedicated group (P < 0.05). Statin use was higher in elderly patients with cardiovascular disease; the intensity of drug use decreased with age. The patients' cardiac function, glucose metabolism, and prognosis were significantly improved after statin treatment.

Aspirin and statin therapy for primary prevention of cardiovascular disease in older adults

The value of primary preventative therapies for cardiovascular disease (CVD) in older adults (age ≥75 years) is less certain than in younger patients. There is a lack of quality evidence in older adults due to underenrolment in pivotal trials. While aspirin is no longer recommended for routine use in primary prevention of CVD in older adults, statins may be efficacious. However, it is unclear which patient subgroups may benefit most, and guidelines differ between expert panels. Three relevant geriatric conditions (cognitive impairment, functional impairment and polypharmacy) may influence therapeutic decision making; for example, baseline frailty may affect statin efficacy, and some have advocated for deprescription in this scenario. Evidence regarding statins and incident functional decline are mixed, and vigilance for adverse effects is important, especially in the setting of polypharmacy. However, aspirin has not been shown to affect incident cognitive or functional decline, and its lack of efficacy extends to patients with baseline cognitive impairment or frailty. Ultimately, the utility of primary preventative therapies for CVD in older adults depends on potential lifetime benefit. Rather than basing treatment decisions on absolute risk alone, consideration of comorbidities, polypharmacy and life expectancy should play a significant role in decision making. Coronary calcium score and new tools for risk stratification validated in older adults that account for the competing risk of death may aid in evaluating potential benefits. Given the complexity of therapeutic decisions in this context, shared decision making provides an important framework.

Statin use in older people primary prevention on cardiovascular disease: an updated systematic review and meta-analysis

Background

Evidence on statin use for primary prevention of cardiovascular disease (CVD) in older people needs to be extended and updated, aiming to provide further guidance for clinical practice.

Methods

PubMed, EMBASE, Cochrane Library and Web of Science were searched for eligible observational studies comparing statin use vs. no-statin use for primary prevention of CVD in older people (age ≥ 65 years). The primary outcomes were all-cause mortality, CVD mortality, coronary heart disease (CHD)/myocardial infraction (MI), stroke and total CV events. Risk estimates of each relevant outcome were synthesized as a hazard ratio (HR) with 95% confidence interval (95% CI) using in the random-effects model.

Results

Twelve eligible observational studies (n = 1,627,434) were enrolled. The pooled results suggested that statin use was associated with a significantly decreased risk of all-cause mortality (HR: 0.54, 95% CI: 0.46-0.63), CVD mortality (HR: 0.51, 95% CI: 0.39-0.65), CHD/MI (HR: 0.83, 95% CI: 0.69-1.00), stroke (HR: 0.79, 95% CI: 0.68-0.92) and total CV events (HR: 0.75, 95% CI: 0.66-0.85). The association in all-cause mortality still remained obvious at higher ages ( ≥ 70 years old, HR: 0.56, 95% CI: 0.44-0.71; ≥ 75 years old, HR: 0.70, 95% CI: 0.60-0.80; ≥ 85 years old, HR: 0.85, 95% CI: 0.74-0.97), ≥ 20% (HR: 0.47, 95% CI: 0.35-0.62) and < 20% diabetic populations (HR: 0.50, 95% CI: 0.40-0.64), and ≥ 50% (HR: 0.68, 95% CI: 0.59-0.79) and < 50% hypertensive populations (HR: 0.38, 95% CI: 0.16-0.88).

Conclusions

Statin use was related to a 46%, 49%, 17%, 21% and 25% risk reduction on all-cause mortality, CVD mortality, CHD/MI, stroke and total CV events in older patients, respectively. The significant association was also addressed in older patients and ≥ 75 years old individuals for CVD primary prevention.

7-Acetoxyhorminone from Salvia multicaulis Vahl. as Promising Inhibitor of 3-Hydroxy-3-methylglutaryl Coenzyme A (HMG-CoA) Reductase

3-Hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase is a key enzyme involved in cholesterol biosynthesis and one of the most important targets for the treatment of hypercholesterolemia. A limited number of studies on the HMG-CoA reductase inhibitory potential of natural products are available. Thus, in the current study, we aimed to test the HMG-CoA reductase inhibitory capacity of extracts from the roots and aerial parts of Salvia multicaulis Vahl., through activity-guided isolation. Our findings revealed that the root extract prepared with dichloromethane–acetone (1:1) showed the highest inhibition (71.97 ± 0.37%) at 100 µg/mL. The extract was then initially fractionated by column chromatography and the obtained fractions were monitored by thin layer chromatography. Fractions which were similar to each other were combined and a total of 15 fractions were obtained. Further conventional chromatographic studies were carried out on the active fractions. Based on these fractions, 10 known compounds, comprising 9 terpenes and 1 steroid derivative in total, were isolated and their structures were verified by a combination of IT-TOF-MS, and 1D and 2D NMR techniques. According to the enzyme inhibition data of the identified compounds, 7-acetoxyhorminone exerted the highest inhibition (84.15 ± 0.10%, IC50 = 63.6 ± 1.21 µg/mL). The molecular docking experiments on 7-acetoxyhorminone and horminone indicated that both compounds strongly bind to the active site of the enzyme.

Is rosuvastatin protective against sepsis-associated encephalopathy? A secondary analysis of the SAILS trial

BACKGROUND

Sepsis is a common cause of death in emergency departments and sepsis-associated encephalopathy (SAE) is a major complication. Rosuvastatin may play a neuroprotective role due to its protective effects on the vascular endothelium and its anti-inflammatory functions. Our study aimed to explore the potential protective function of rosuvastatin against SAE.

METHODS

Sepsis patients without any neurological dysfunction on admission were prospectively enrolled in the "Rosuvastatin for Sepsis-Associated Acute Respiratory Distress Syndrome" study (SAILS trial, ClinicalTrials.gov number: NCT00979121). Patients were divided into rosuvastatin and placebo groups. This is a secondary analysis of the SAILS dataset. Baseline characteristics, therapy outcomes, and adverse drug events were compared between groups.

RESULTS

A total of 86 patients were eligible for our study. Of these patients, 51 were treated with rosuvastatin. There were significantly fewer cases of SAE in the rosuvastatin group than in the placebo group (32.1% vs. 57.1%, P=0.028). However, creatine kinase levels were significantly higher in the rosuvastatin group than in the placebo group (233 [22-689] U/L vs. 79 [12-206] U/L, P=0.034).

CONCLUSION

Rosuvastatin appears to have a protective role against SAE but may result in a higher incidence of adverse events.

Statin Discontinuation and Cardiovascular Events Among Older People in Denmark

Importance

Statin use is common in older persons. Given uncertainties in ongoing benefit, changes in health status, and shifting goals of care and preferences, statin discontinuation may be considered in some older persons, although there is currently little evidence to guide this decision.

Objective

To evaluate the association between statin discontinuation and the rate of major adverse cardiovascular events (MACE) among people aged 75 years or older who receive long-term statin treatment.

Design, Setting, and Participants

This cohort study included all persons in Denmark aged 75 years or older who were treated with statins for at least 5 consecutive years as of January 1, 2011. Participants were followed up until December 31, 2016. Data were analyzed from July to November, 2020.

Exposure

Statin discontinuation.

Main Outcomes and Measures

Rate of occurrence of MACE and its components (myocardial infarction, ischemic stroke or transient ischemic attack, coronary revascularization, and death due to myocardial infarction or ischemic stroke) in persons continuing statins compared with those discontinuing statins. Confounding adjustment was done using inverse probability of treatment weighting. Analyses were conducted separately for primary prevention (no history of cardiovascular disease) and secondary prevention (history of cardiovascular disease).

Results

The study included 67 418 long-term statin users, including 27 463 in the primary prevention analysis (median age, 79 years [IQR, 77-83 years]; 18 134 [66%] female) and 39 955 in the secondary prevention analysis (median age, 80 years [IQR, 77-84 years]; 18 717 [47%] female). In both primary and secondary prevention analyses, the rate of MACE was higher among persons who discontinued statins compared with those who continued statins. In the primary prevention cohort, the weighted rate difference was 9 per 1000 person-years (95% CI, 5-12 per 1000 person-years) and the adjusted sub-hazard ratio was 1.32 (95% CI, 1.18-1.48), corresponding to 1 excess MACE per 112 persons who discontinued statins per year. In the secondary prevention cohort, the weighted rate difference was 13 per 1000 person-years (95% CI, 8-17 per 1000 person-years) and the adjusted sub-hazard ratio was 1.28 (95% CI, 1.18-1.39), corresponding to 1 excess MACE per 77 persons who discontinued statins per year.

Conclusions and Relevance

In this cohort study, among older adults receiving long-term statin treatment, discontinuation of statins was associated with a higher rate of MACE compared with statin continuation in both the primary and the secondary prevention cohorts. These findings suggest a need for robust evidence from randomized clinical trials.

Association of statin use in older people primary prevention group with risk of cardiovascular events and mortality: a systematic review and meta-analysis of observational studies

BACKGROUND

Current evidence from randomized controlled trials on statins for primary prevention of cardiovascular disease (CVD) in older people, especially those aged > 75 years, is still lacking. We conducted a systematic review and meta-analysis of observational studies to extend the current evidence about the association of statin use in older people primary prevention group with risk of CVD and mortality.

METHODS

PubMed, Scopus, and Embase were searched from inception until March 18, 2021. We included observational studies (cohort or nested case-control) that compared statin use vs non-use for primary prevention of CVD in older people aged ≥ 65 years; provided that each of them reported the risk estimate on at least one of the following primary outcomes: all cause-mortality, CVD death, myocardial infarction (MI), and stroke. Risk estimates of each relevant outcome were pooled as a hazard ratio (HR) with a 95% confidence interval (CI) using the random-effects meta-analysis model. The quality of the evidence was rated using the GRADE approach.

RESULTS

Ten observational studies (9 cohorts and one case-control study; n = 815,667) fulfilled our criteria. The overall combined estimate suggested that statin therapy was associated with a significantly lower risk of all-cause mortality (HR: 0.86 [95% CI 0.79 to 0.93]), CVD death (HR: 0.80 [95% CI 0.78 to 0.81]), and stroke (HR: 0.85 [95% CI 0.76 to 0.94]) and a non-significant association with risk of MI (HR 0.74 [95% CI 0.53 to 1.02]). The beneficial association of statins with the risk of all-cause mortality remained significant even at higher ages (> 75 years old; HR 0.88 [95% CI 0.81 to 0.96]) and in both men (HR: 0.75 [95% CI: 0.74 to 0.76]) and women (HR 0.85 [95% CI 0.72 to 0.99]). However, this association with the risk of all-cause mortality remained significant only in those with diabetes mellitus (DM) (HR 0.82 [95% CI 0.68 to 0.98]) but not in those without DM. The level of evidence of all the primary outcomes was rated as "very low."

CONCLUSIONS

Statin therapy in older people (aged ≥ 65 years) without CVD was associated with a 14%, 20%, and 15% lower risk of all-cause mortality, CVD death, and stroke, respectively. The beneficial association with the risk of all-cause mortality remained significant even at higher ages (> 75 years old), in both men and women, and in individuals with DM, but not in those without DM. These observational findings support the need for trials to test the benefits of statins in those above 75 years of age.

Age-Related Trajectories of Cardiovascular Risk and Use of Aspirin and Statin Among U.S. Adults Aged 50 or Older, 2011-2018

OBJECTIVES

To examine age-related trajectories of cardiovascular risk and use of aspirin and statin among U.S. adults aged 50 or older.

DESIGN

Repeated cross-sectional study using data from 2011 to 2018 National Health and Nutrition Examination Surveys.

SETTING

Nationally representative health interview survey in the United States.

PARTICIPANTS

Non-institutionalized adults aged 50 years and older (n = 11,392 unweighted).

MEASUREMENTS

Primary prevention was defined as the prevention of a first cardiovascular event including coronary heart disease, angina/angina pectoris, heart attack, or stroke, whereas secondary prevention was defined as those with a history of these clinical conditions. Medication use was determined by self-report; aspirin use included dose and frequency, and statin use included generic names, days of prescription fills, and indications. We examined linear trends between age and each medication use, after controlling for period, sex, and race/ethnicity.

RESULTS

Prevalence of those eligible for primary prevention treatment increased with age from 31.8% in ages 50-54 to 52.0% in ages ≥75 (p < 0.001). Similarly, those eligible for secondary prevention treatment increased with age from 2.7% in ages 50-54 to 21.1% in ages ≥75 (p < 0.001). Low-dose daily aspirin use increased with age (p < 0.001), and 45.3% of adults aged ≥75 took low-dose aspirin daily for primary prevention. Statin use also increased with age (p < 0.001), and 56.4% of adults aged ≥75 had long-term statin use for secondary prevention.

CONCLUSION

While adults aged ≥75 do not benefit from the use of aspirin to prevent the first CVD, many continue to take aspirin on a regular basis. In spite of the clear benefit of statin use to prevent a subsequent CVD event, many older adults in this risk category are not taking a statin. Further education and guidance for both healthcare providers and older adults regarding the appropriate use of aspirin and statins to prevent CVD is needed.

Impact of Adherence, Patient Perception, and Knowledge to Statin Therapy - A Cross-Sectional Study

BACKGROUND AND OBJECTIVE

Cardiovascular diseases and its risk factors, such as diabetes and hyperlipidemia, are common in Indian population. Statin utilization is high across the country and it is important to assess the adherence because it plays an important role in treatment outcome. Statin adherence is not studied well in India. This study aims at measuring the adherence, perception, and knowledge of individuals on statin therapy.

STUDY DESIGN

Cross-sectional observational study on 130 consented individuals visiting a tertiary care teaching hospital. Study was conducted for a duration of 9 months.

METHODS AND MATERIALS

After obtaining approval from the institutional ethics committee the study subjects were assessed for knowledge, perception, and adherence to statin therapy using a systematically developed interview questionnaire.

RESULTS

Good adherence was seen in 42.30% patients. Higher proportions of females were reported to have good adherence. Good adherence was observed in patients with a history of coronary heart disease and atorvastatin as monotherapy (P = 0.0029) and fixed dose combination (P = 0.0012), whereas lipid reduction was found directly related to type of adherence. Lack of knowledge, cost, re-fill issues, and adverse effects were some of the barriers identified.

INTERPRETATION AND CONCLUSION

Knowledge and patient perception plays a very important role in determining the adherence to statin therapy. A history of coronary heart disease, choice of statin, and cost of therapy are the contributing factors to adherence. Patient counselling and improving the cost-effectiveness of statin therapy can be considered as interventional strategies to overcome adherence issues.

The gut microbiota is associated with clinical response to statin treatment in patients with coronary artery disease

BACKGROUND

The structure and composition of the gut microbiota influence patients' response to therapeutic interventions. It is also known that the response to statin treatment can vary greatly from one patient to another, suggesting a possible connection between microbiome composition and response to statins. In the present study, we aim to explore the influence of the microbiome composition on the response to statin treatment among patients with coronary artery disease (CAD).

METHODS

A prospective cohort of 836 CAD patients enrolled from January 2016 to December 2017 was used to perform a nested case-control study. We divided 110 CAD patients into two groups according to their response to statins (good response group and poor response group) and compared their gut microbiota.

RESULTS

Our analysis reveals no significant difference in microbiome between the two groups. However, significant differences were found in the relative proportion of numerous genera between GR and PR groups. Most remarkably, we could observe that a poor response to statin treatment correlates to a significant decrease in the abundance of beneficial bacteria for the lipid metabolism (Akkermansia muciniphila (A. muciniphila) and Lactobacillus) and a significant increase in the abundance of bacteria (Holdemanella and Facecallibacterium).

CONCLUSIONS

Gut microbiota structure is associated with the response to statin. Our results suggest that manipulation of the gut microbiota composition can be an interesting and effective treatment strategy to blood lipid control among CAD patients.

Underprescription of medications in older adults: causes, consequences and solutions-a narrative review

PURPOSE

Under-prescription is defined as the omission of a medication that is indicated for the treatment of a condition or a disease, without any valid reason for not prescribing it. The aim of this review is to provide an updated overview of under-prescription, summarizing the available evidence concerning its prevalence, causes, consequences and potential interventions to reduce it.

METHODS

A PubMed search was performed, using the following keywords: under-prescription; under-treatment; prescribing omission; older adults; polypharmacy; cardiovascular drugs; osteoporosis; anticoagulant. The list of articles was evaluated by two authors who selected the most relevant of them. The reference lists of retrieved articles were screened for additional pertinent studies.

RESULTS

Although several pharmacological therapies are safe and effective in older patients, under-prescription remains widespread in the older population, with a prevalence ranging from 22 to 70%. Several drugs are underused, including cardiovascular, oral anticoagulant and anti-osteoporotic drugs. Many factors are associated with under-prescription, e.g. multi-morbidity, polypharmacy, dementia, frailty, risk of adverse drug events, absence of specific clinical trials in older patients and economic factors. Under-prescription is associated with negative consequences, such as higher risk of cardiovascular events, worsening disability, hospitalization and death. The implementation of explicit criteria for under-prescription, the use of the comprehensive geriatric assessment by geriatricians, and the involvement of a clinical pharmacist seem to be promising options to reduce under-prescription.

CONCLUSION

Under-prescription remains widespread in the older population. Further studies should be performed, to provide a better comprehension of this phenomenon and to confirm the efficacy of corrective interventions.

Statin Treatment in Specific Patient Groups: Role for Improved Cardiovascular Risk Markers

Ample evidence supports the use of statin therapy for secondary prevention in patients with a history of atherosclerotic cardiovascular disease (ASCVD), but evidence is wanting in the case of primary prevention, low-risk individuals, and elderly adults 65+. Statins are effective in lowering low-density lipoprotein (LDL), which has long been a target for treatment decisions. We discuss the weakening dependence between cholesterol levels and mortality as a function of age and highlight recent findings on lipoprotein subfractions and other superior markers of ASCVD risk. The efficacy of statins is compared for distinct subsets of patients based on age, diabetes, ASCVD, and coronary artery calcium (CAC) status. Most cardiovascular risk calculators heavily weight age and overestimate one's absolute risk of ASCVD, particularly in very old adults. Improvements in risk assessment enable the identification of specific patient populations that benefit most from statin treatment. Derisking is particularly important for adults over 75, in whom treatment benefits are reduced and adverse musculoskeletal effects are amplified. The CAC score stratifies the benefit effect size obtainable with statins, and forms of coenzyme Q are discussed for improving patient outcomes. Robust risk estimator tools and personalized, evidence-based approaches are needed to optimally reduce cardiovascular events and mortality rates through administration of cholesterol-lowering medications.

Effects of Statins for Primary Prevention in the Elderly: Recent Evidence

The number of the elderly individuals is steeply increasing, and their absolute cardiovascular risk is higher than that of younger age groups. However, very few statin trials have included elderly patients alone. Recently, we published the SCOPE-75 study, which analyzed the effect of statins for primary prevention in elderly Koreans (>75 years). In this study, statin users showed significantly fewer cardiovascular events and a lower all-cause mortality rate, supporting more active use of statins in this population. In the current review, we further compare and discuss similar studies reported in the past decades and in recent years.

Effects of Statin Use for Primary Prevention among Adults Aged 75 Years and Older in the National Health Insurance Service Senior Cohort (2002-2015)

BACKGROUND

This study aimed to identify adverse events and mortality in adults aged 75 years and older who were initially prescribed statins for primary prevention.

METHODS

This retrospective study analyzed the data from the National Health Insurance Corporation-Senior Cohort from 2002 to 2015. An exact block matched model was constructed from statin user and statin non-user groups.

RESULTS

The study sample comprised 1,370 older adults (mean age, 78 years), with 685 statin non-users matched to 685 new statin users. Compared to non-users, the adjusted hazard ratios (HRs) of new statin users were 0.83 (p=0.04) for all-cause mortality, 1.24 (p=0.03) for major adverse cardiovascular events, and 1.18 (p=0.06) for new-onset diabetes mellitus. In a sub-analysis of statin use duration, longer statin use (>5 years) was associated with a significantly lower risk of all-cause mortality (HR=0.76, p=0.01) but not with major adverse cardiovascular events (HR=0.88, p=0.36) or new-onset diabetes mellitus (HR=0.95, p=0.78) after adjusting for age, sex, body mass index, diabetes mellitus, hypertension, aspirin use, and antiplatelet use.

CONCLUSION

Our findings suggested that statins started for primary prevention in older adults aged 75 years and older had an advantageous effect on all-cause mortality only if used for at least 5 years.

Treating Dyslipidemias in the Primary Prevention of Atherosclerotic Cardiovascular Disease in Older Adults with Diabetes Mellitus

People with diabetes mellitus (DM), especially those who are older, are at higher risk for premature morbidity and mortality related to atherosclerotic cardiovascular disease (ASCVD). Clinical practice guidelines recommend statin therapy for people with DM ages 40 to 75 years. The evidence for those greater than 75 years of age is relatively limited at present. Other health problems should be considered when planning ASCVD primary prevention in adults ages greater than 75 years with DM. Clinicians should discuss the risks and benefits of each plan with these patients and their caregivers.

Mortality and Cholesterol Metabolism in Subjects Aged 75 Years and Older: The Helsinki Businessmen Study

BACKGROUND/OBJECTIVES

In many studies, low serum cholesterol is paradoxically associated with a higher mortality risk among older adults. Therefore, we studied whole-body cholesterol metabolism and its role in all-cause mortality of older men in two subcohorts of different ages.

DESIGN

Prospective long-term cohort.

SETTING

Home-dwelling men of the Helsinki Businessmen Study.

PARTICIPANTS

Two partly overlapping subcohorts were recruited, in 2003 (n = 660; mean age = 76 years) and in 2011 (n = 398; mean age = 83 years). The younger subcohort was followed up after 3 and 11 years, and the older subcohort was followed up after 3 years.

MEASUREMENTS

Cholesterol metabolism was assessed via serum noncholesterol sterol-cholesterol ratios, and quantification was performed by gas-liquid chromatography with flame ionization detection. All statistical analyses were performed with age and statin treatment as covariates.

RESULTS

At the end of the 3-year follow-up, 10% of the younger and 13% of the older subcohort had died; and at the end of the 11-year follow-up, 40% of the younger subcohort had died. Serum total and low-density lipoprotein (LDL) cholesterol and cholesterol precursors reflecting cholesterol synthesis were lower in the older than in the younger subcohort (P < .001 for all). In the older subcohort, low serum campesterol and sitosterol, reflecting decreased cholesterol absorption efficiency, predicted all-cause mortality (P < .05). This was supported by a trend toward low serum campesterol and sitosterol predicting mortality (P = .088 and P = .079, respectively) in the younger subcohort after 11 years. Cholesterol synthesis did not predict mortality, but in the older subcohort, decreased cholesterol absorption was less efficiently compensated for by decreased cholesterol synthesis.

CONCLUSIONS

Low cholesterol absorption efficiency predicted all-cause mortality, especially in men aged 83 years on average, and cholesterol synthesis was lowered. These metabolic changes could contribute to the lowering of serum total and LDL-cholesterol in older men. J Am Geriatr Soc 68:281-287, 2020.

Genetically-predicted life-long lowering of low-density lipoprotein cholesterol is associated with decreased frailty: A Mendelian randomization study in UK biobank

Background

High circulating low-density lipoprotein cholesterol (LDL-C) is a major risk factor for atherosclerosis and age-associated cardiovascular events. Long-term dyslipidaemia could contribute to the development of frailty in older individuals through its role in determining cardiovascular health and potentially other physiological pathways.

Methods

We conducted Mendelian randomization (MR) analyses using genetic variants to estimate the effects of long-term LDL-C modification on frailty in UK Biobank (n = 378,161). Frailty was derived from health questionnaire and interview responses at baseline when participants were aged 40 to 69 years, and calculated using an accumulation-of-deficits approach, i.e. the frailty index (FI). Several aggregated instrumental variables (IVs) using 50 and 274 genetic variants were constructed from independent single-nucleotide polymorphisms (SNPs) to instrument circulating LDL-C concentrations. Specific sets of variants in or near genes that encode six lipid-lowering drug targets (HMGCR, PCSK9, NPC1L1, APOB, APOC3, and LDLR) were used to index effects of exposure to related drug classes on frailty. SNP-LDL-C effects were available from previously published studies. SNP-FI effects were obtained using adjusted linear regression models. Two-sample MR analyses were performed with the IVs as instruments using inverse-variance weighted, MR-Egger, weighted median, and weighted mode methods. To address the stability of the findings, MR analyses were also performed using i) a modified FI excluding the cardiometabolic deficit items and ii) data from comparatively older individuals (aged ≥60 years) only. Several sensitivity analyses were also conducted.

Findings

On average 0.14% to 0.23% and 0.16% to 0.31% decrements in frailty were observed per standard deviation reduction in LDL-C exposure, instrumented by the general IVs consisting of 50 and 274 variants, respectively. Consistent, though less precise, associations were observed in the HMGCR-, APOC3-, NPC1L1-, and LDLR-specific IV analyses. In contrast, results for PCSK9 were in the same direction but more modest, and null for APOB. All sensitivity analyses produced similar findings.

Interpretation

A genetically-predicted life-long lowering of LDL-C is associated with decreased frailty in midlife and older age, representing supportive evidence for LDL-C's role in multiple health- and age-related pathways. The use of lipid-lowering therapeutics with varying mechanisms of action may differ by the extent to which they provide overall health benefits.