Management of Hypercholesterolemia in Older Persons for the Prevention of Cardiovascular Disease

Drug Therapy of Dyslipidemia in the Elderly

Abnormal lipoprotein metabolism is an important and modifiable risk factor for atherosclerotic cardiovascular disease (ASCVD), which has been shown in numerous studies to lead to adverse cardiovascular outcomes. As cardiovascular disease (CVD) remains the major cause of morbidity and mortality globally, management of dyslipidemia is a key component of primary and secondary risk-reduction strategies. Because ASCVD risk increases with age, as the population ages, many more people-particularly the elderly-will meet guideline criteria for drug treatment. Statins (HMG-CoA reductase inhibitors) have an unequivocal benefit in reducing ASCVD risk across age groups for secondary prevention. However, the benefit of these drugs for primary prevention in those > 75 years of age remains controversial. We strongly believe that statins should be offered for primary prevention to all older individuals after a shared decision-making process that takes polypharmacy, frailty, and potential adverse effects into consideration. When considering statin therapy in the very old, competing risks of death, and therefore the likelihood that patients will live long enough to benefit from drug therapy, should inform this process. Combination therapies with ezetimibe or proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors should be considered to facilitate the use of tolerable doses of statins. Future investigations of dyslipidemia therapies must appropriately include this at-risk population to identify optimal drugs and drug combinations that have a high benefit:risk ratio for the prevention of ASCVD in the elderly.

Hypolipidemic drugs in elderly subjects: Indications and limits

AIMS

Cardiovascular disease is a major cause of death worldwide. Safety and efficacy of lipid lowering therapy have been clearly established for either primary and secondary prevention of cardiovascular events in adults. Nevertheless, the use of hypolipidemic drugs in elderly individuals, especially in the oldest ones, still raises some concerns. Aim of this paper is to review indications and limits of lipid lowering in advanced age, furnishing a practical medical attitude tempered by clinical and geriatric competences.

DATA SYNTHESIS

While figures from randomized controlled trials and from observational studies seem to support the use of lipid lowering drugs for secondary prevention in the elderly, drawing inferences from primary prevention in old populations is far more challenging. Although these pharmacological agents seem to reduce the incidence of cardiovascular events, they do not prolong survival. In addition, there is some doubt about the cost-effectiveness of treatment because of a more delicate balance between benefit and potential adverse reactions. However, lipid-lowering drugs seem largely underutilized in older age, mainly due to safety concerns that must be reconsidered, at least in part, given the somewhat reassuring results deriving from specific cohort surveys.

CONCLUSIONS

Data on the use and on the effects of lipid lowering drugs in elderly populations are incomplete, especially those concerning very old subjects without established cardiovascular disease. Comprehensive guidelines for the management of dyslipidemias in this rapidly-growing population is a urgent need, and treatment should be based, besides the aforementioned considerations, on patient preferences, cognitive function and life expectancy.

Supplementation with Aspergillus oryzae-fermented kochujang lowers serum cholesterol in subjects with hyperlipidemia

BACKGROUND & AIMS

Kochujang, a traditional fermented red pepper paste, is known for its hypocholesterolemic effect; however, these studies used non-commercial preparations of kochujang. In this study, we examined whether commercially-made kochujang in which Aspergillus oryzae (also known as koji) was used as a microorganism for fermentation has the same cholesterol-lowering effects.

METHODS

Hyperlipidemic subjects (based upon criteria of 110 ∼ 190 mg/dL LDL cholesterol or 200 ∼ 260 mg/dL total cholesterol) who had not been diagnosed with any disease and met the inclusion criteria were recruited for this study. The 30 subjects were randomly divided into either the kochujang (n = 15) or placebo (n = 15) group. All subjects ingested either the kochujang pill (34.5 g/d) or a placebo three times daily during meals for 12 weeks. Outcomes included measurements of efficacy (total cholesterol, LDL-cholesterol, HDL-cholesterol, and triglyceride) and safety (adverse events, laboratory tests, electrocardiogram, and vital signs).

RESULTS

In the kochujang-supplemented group, subjects' total cholesterol level significantly decreased (from 215.5 ± 16.1 mg/dL to 194.5 ± 25.4 mg/dL, p = 0.001). LDL-C cholesterol levels were also decreased by kochujang supplementation (from 133.6 ± 14.8 mg/dL to 113.5 ± 23.1 mg/dL); however no significant difference was seen between groups (p = 0.074). There were no statistically significant differences in HDL-cholesterol and triglyceride levels between the supplemented and non-supplemented groups. None of the subjects complained of any adverse effects.

CONCLUSIONS

These results indicate that A. oryzae-fermented kochujang elicits a significant hypocholesterolemic effect and might be useful for improving blood cholesterol levels in subjects at high risk for cardiovascular disease.

CLINICAL TRIAL REGISTRATION

NCT01865370.

Influence of diabetes mellitus on inappropriate and appropriate implantable cardioverter-defibrillator therapy and mortality in the Multicenter Automatic Defibrillator Implantation Trial-Reduce Inappropriate Therapy (MADIT-RIT) Trial

BACKGROUND

The relationship between diabetes mellitus and risk of inappropriate or appropriate therapy in patients receiving an implantable cardioverter-defibrillator (ICD) and resynchronization therapy has not been investigated thoroughly. The effect of innovative ICD programming on therapy delivery in these patients is unknown.

METHODS AND RESULTS

The Multicenter Automatic Defibrillator Implantation Trial-Reduce Inappropriate Therapy (MADIT-RIT) randomized patients with a primary prophylactic ICD indication to 3 different types of ICD programming: conventional programming with a ventricular tachycardia zone of 170 to 199 bpm (arm A), high-rate cutoff with a ventricular tachycardia zone ≥200 bpm (arm B), or 60-second-delayed therapy (arm C). The end points of inappropriate therapy, appropriate therapy, and death were assessed among 485 patients with and 998 without diabetes mellitus. Innovative ICD programming reduced the risk of inappropriate therapy regardless of diabetes mellitus, although a trend toward a more pronounced effect of high-rate cutoff programming was seen in patients without diabetes mellitus (P for interaction=0.06). Diabetes mellitus was associated with a decreased risk of inappropriate therapy (hazard ratio, 0.54; 95% confidence interval, 0.36-0.80; P=0.002) and increased risk of appropriate therapy (hazard ratio, 1.58; 95% confidence interval, 1.17-2.14; P=0.003). In diabetic patients, there was significantly increased risk of death in those who had inappropriate therapy (hazard ratio, 4.17; 95% confidence interval, 1.52-11.40; P=0.005) and appropriate therapy (hazard ratio, 2.49; 95% confidence interval, 1.06-5.87; P=0.037) compared with those who did not.

CONCLUSIONS

Innovative high-rate cutoff or delayed ICD programming was associated with a reduction in inappropriate therapy in patients with and without diabetes mellitus. Diabetes mellitus was associated with lower risk of inappropriate therapy but higher risk of appropriate therapy. Appropriate and inappropriate ICD therapy was associated with increased mortality in diabetic patients.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. UNIQUE IDENTIFIER: NCT00947310.

Health maintenance in older adults: combining evidence and individual preferences

There is increasing interest in maintaining health and delaying disability for older adults as this population segment expands. And instead of focusing on a traditional disease-specific approach to health maintenance, there is an ongoing shift to a patient-centered approach, and defining outcomes based on the older adults' goals. In this approach, their goals and preferences are central, and other factors such as their health status and prognosis help determine which goals may be realistic. These subjective goals and objective characteristics are then balanced with the risks, benefits, and harms of established evidence-driven health-maintenance recommendations. Hence, older adults share their goals and preferences with clinicians; while clinicians share information on risks, benefits, harms, and uncertainties of existing health-maintenance recommendations, and help guide the older adult through how existing evidence can respond to their health goals and preferences. In this article, the concept of patient-centered care in the context of health maintenance for older adults is discussed; and health maintenance recommendations for older adults are reviewed.

Cardiovascular and mortality risks in Parkinson's disease patients treated with entacapone

The controlled trial Stalevo Reduction in Dyskinesia Evaluation in Parkinson's Disease (STRIDE-PD) reported an unexpected increase in acute myocardial infarction (AMI) with entacapone use in patients with Parkinson's disease (PD). The authors investigated whether entacapone increased cardiovascular and mortality risk compared with the use of a non-levodopa dopamine agonist (DA) or a selective monoamine oxidase type-B inhibitor (MAOBI). Using national Medicare data, a new-user cohort of elderly patients with PD treated with entacapone was propensity score (PS) matched with new users of either DA or MAOBI. The PS model included variables for sociodemographics, cardiovascular disease, medications, prior PD treatment, and comorbidities. Cox proportional hazards regression was used to compare on-therapy time to event for AMI, stroke, and death with DA-MAOBI as a reference. Study cohorts included 8681 entacapone-treated and 17,362 DA-MAOBI-treated initators who were followed for 2569 and 5385 person-years, respectively. Cohorts were closely balanced for all covariates. During follow-up, there were 106 AMIs, 89 strokes, and 201 deaths. The hazard ratio (HR) and 95% confidence interval (CI) associated with entacapone use was 0.86 (95% CI, 0.57-1.30) for AMI, 0.85 (95% CI, 0.54-1.35) for stroke, and 0.79 (95% CI, 0.58-1.07) for death. The risk was unchanged for treatment of ≤ 6 months' and>6 months' duration and was unaffected by adjustment for time-varying levodopa use during follow-up. The risk of each endpoint was not differentially affected by diabetes, ischemic heart disease, or kidney failure status. However, the risk of stroke was modified by the presence (HR, 2.09; 95% CI, 0.98-4.45) or absence (HR, 0.51; 95% CI, 0.27-0.95) of advanced PD-related morbidities (P value for interaction=0.004). Entacapone was not associated with an increased risk of AMI, stroke, or death in elderly patients with PD.