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

Statin therapy and cardiovascular protection in type 2 diabetes: The role of baseline LDL-Cholesterol levels. A systematic review and meta-analysis of observational studies

AIM

The guidelines recommend statins to prevent cardiovascular events in patients with type 2 diabetes (T2D) however, the importance of baseline LDL-Cholesterol (LDL-C) levels remains controversial. This study aimed to determine the association of statin use in T2D patients with major adverse cardiovascular events (MACE) and all-cause mortality and whether this association differs by baseline LDL-C levels.

DATA SYNTHESIS

Medline, Embase, and Web of Science were systematically searched from inception until January 2022. Observational studies in patients with T2D comparing statin users vs non-users, with reports of the baseline LDL-C levels, were included. Random-effects meta-analysis and meta-regression were performed to estimate the overall effect on the risk of all-cause mortality and MACE (a composite of myocardial infarction, heart failure, stroke, and revascularization events) and the modification in the association by baseline LDL-C levels. We categorized studies according to their baseline LDL-C levels into 1) <100 mg/dl (2.59 mmol/l), 2) 100-130 mg/dl (2.59-3.37 mmol/l) and 3) >130 mg/dl (3.37 mmol/l) categories. A total of 9 cohort studies (n = 403,411 individuals) fulfilled our criteria. The follow-up duration ranged from 1.7 to 8 years. The overall combined estimate showed that statin therapy was associated with a significantly lower risk of MACE (Hazard Ratio (HR): 0.70 [95% CI 0.59 to 0.83], Absolute risk reduction percentage (ARR%): 3.19% [95%CI 0.88 to 5.50%) and all-cause mortality (HR: 0.60 [95% CI 0.46 to 0.79], ARR%: 5.23% [95% CI 2.18 to 8.28%), but varied, albeit not statistically significant, by baseline LDL-C levels. Studies with baseline LDL-C levels higher than 130 mg/dl had the greatest reduction of MACE (HR: 0.58 [95% CI 0.37 to 0.90]) and all-cause mortality risk (HR: 0.51 [95% CI [ 0.29 to 0.90]). The HRs of MACE in studies with LDL-C levels of 100-130 mg/dl and <100 mg/dl categories were respectively (0.70 [95% CI 0.59 to 0.83]) and (0.83 [95% CI [0.68 to 1.00]); and that of all-cause mortality were respectively (0.62 [95% CI 0.38 to 1.01]) and (0.67 [95% CI [0.44 to 1.02]). Statin use changes the HRs of MACE (0.99 [95%CI, 0.98 to 0.99]; P = 0.04) and all-cause mortality (0.99 [95% CI 0.98 to 1.01]; P = 0.8) per each mg/dl increase in baseline LDL-C level in meta-regression analyses.

CONCLUSION

Statin therapy in patients with T2D was associated with reduced risk of MACE and all-cause mortality. Significant differences across studies with different baseline LDL-C levels were not observed.

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.

[Prevention of ischemic stroke in old age]

Stroke is one of the main causes of permanent disability and death and the risk increases with age. Primary and secondary prevention therefore have a high priority. The treatment of risk factors, such as high blood pressure, diabetes mellitus and hyperlipidemia is just as important as anticoagulation in atrial fibrillation, in addition to optimization of lifestyle and diet. Platelet function inhibitors play a role in the prophylaxis of recurrence, carotid surgery and stenting are used in selected patients. There is little study evidence for old people, individualized treatment planning takes functional status and comorbidities into account.

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.

Effect modification by statin use status on the association between fine particulate matter (PM2.5) and cardiovascular mortality

BACKGROUND

Numerous studies have linked fine particulate matter (PM2.5) to increased cardiovascular mortality. Less is known how the PM2.5-cardiovascular mortality association varies by use of cardiovascular medications. This study sought to quantify effect modification by statin use status on the associations between long-term exposure to PM2.5 and mortality from any cardiovascular cause, coronary heart disease (CHD), and stroke.

METHODS

In this nested case-control study, we followed 1.2 million community-dwelling adults aged ≥66 years who lived in Ontario, Canada from 2000 through 2018. Cases were patients who died from the three causes. Each case was individually matched to up to 30 randomly selected controls using incidence density sampling. Conditional logistic regression models were used to estimate odds ratios (ORs) for the associations between PM2.5 and mortality. We evaluated the presence of effect modification considering both multiplicative (ratio of ORs) and additive scales (the relative excess risk due to interaction, RERI).

RESULTS

Exposure to PM2.5 increased the risks for cardiovascular, CHD, and stroke mortality. For all three causes of death, compared with statin users, stronger PM2.5-mortality associations were observed among non-users [e.g. for cardiovascular mortality corresponding to each interquartile range increase in PM2.5, OR = 1.042 (95% CI, 1.032-1.053) vs OR = 1.009 (95% CI, 0.996-1.022) in users, ratio of ORs = 1.033 (95% CI, 1.019-1.047), RERI = 0.039 (95% CI, 0.025-0.050)]. Among users, partially adherent users exhibited a higher risk of PM2.5-associated mortality than fully adherent users.

CONCLUSIONS

The associations of chronic exposure to PM2.5 with cardiovascular and CHD mortality were stronger among statin non-users compared to users.

Life, death, and statins: association of statin prescriptions and survival in older general practice patients

AIMS

This study serves as an exemplar to demonstrate the scalability of a research approach using survival analysis applied to general practice electronic health record data from multiple sites. Collection of these data, the subsequent analysis, and the preparation of practice-specific reports were performed using a bespoke distributed data collection and analysis software tool.

BACKGROUND

Statins are a very commonly prescribed medication, yet there is a paucity of evidence for their benefits in older patients. We examine the relationship between statin prescriptions for general practice patients over 75 and all-cause mortality.

METHODS

We carried out a retrospective cohort study using survival analysis applied to data extracted from the electronic health records of five Australian general practices.

FINDINGS

The data from 8025 patients were analysed. The median duration of follow-up was 6.48 years. Overall, 52 015 patient-years of data were examined, and the outcome of death from any cause was measured in 1657 patients (21%), with the remainder being censored. Adjusted all-cause mortality was similar for participants not prescribed statins versus those who were (HR 1.05, 95% CI 0.92-1.20, P = 0.46), except for patients with diabetes for whom all-cause mortality was increased (HR = 1.29, 95% CI: 1.00-1.68, P = 0.05). In contrast, adjusted all-cause mortality was significantly lower for patients deprescribed statins compared to those who were prescribed statins (HR 0.81, 95% CI 0.70-0.93, P < 0.001), including among females (HR = 0.75, 95% CI: 0.61-0.91, P < 0.001) and participants treated for secondary prevention (HR = 0.72, 95% CI: 0.60-0.86, P < 0.001). This study demonstrated the scalability of a research approach using survival analysis applied to general practice electronic health record data from multiple sites. We found no evidence of increased mortality due to statin-deprescribing decisions in primary care.

Effect of statin use for the primary prevention of cardiovascular disease among older adults: a cautionary tale concerning target trials emulation

OBJECTIVES

Evidence concerning the effect of statins in primary prevention of cardiovascular disease (CVD) among older adults is lacking. Using Quebec population-wide administrative data, we emulated a hypothetical randomized trial including older adults >65 years on April 1, 2013, with no CVD history and no statin use in the previous year.

STUDY DESIGN AND SETTING

We included individuals who initiated statins and classified them as exposed if they were using statin at least 3 months after initiation and nonexposed otherwise. We followed them until March 31, 2018. The primary outcome was the composite endpoint of coronary events (myocardial infarction, coronary bypass, and percutaneous coronary intervention), stroke, and all-cause mortality. The intention-to-treat (ITT) effect was estimated with adjusted Cox models and per-protocol effect with inverse probability of censoring weighting.

RESULTS

A total of 65,096 individuals were included (mean age = 71.0 ± 5.5, female = 55.0%) and 93.7% were exposed. Whereas we observed a reduction in the composite outcome (ITT-hazard ratio (HR) = 0.75; 95% CI: 0.68-0.83) and mortality (ITT-HR = 0.69; 95% CI: 0.61-0.77) among exposed, coronary events increased (ITT-HR = 1.46; 95% CI: 1.09-1.94). All multibias E-values were low indicating that the results were not robust to unmeasured confounding, selection, and misclassification biases simultaneously.

CONCLUSION

We cannot conclude on the effectiveness of statins in primary prevention of CVD among older adults. We caution that an in-depth reflection on sources of biases and careful interpretation of results are always required in observational studies.

Cardiovascular Benefit of Statin Use Against Air Pollutant Exposure in Older Adults

BACKGROUND AND AIMS

Little is known about the cardiovascular benefit of statin use against ambient air pollution among older adults who are at higher risk of cardiovascular disease (CVD) potentially owing to age-related declines in cardiovascular functions along with other risk factors.

METHODS AND RESULTS

This retrospective, population-based cohort study consisted of adults aged 60 years and older free of CVD at baseline identified from the National Health Insurance Service (NHIS) database linked to the National Ambient Air Monitoring Information System (NAMIS) for average daily exposure to PM10 and PM2.5 in 2015 in the major metropolitan areas in the Republic of Korea. Follow-up period began on January 1, 2016 and lasted until December 31, 2021. Cox proportional hazards model was used to evaluate association of cardiovascular benefit with statin use against different levels of air pollutant exposure. Of 1,229,444 participants aged 60 years and older (mean age, 67.4; 37.7% male), 377,076 (30.7%) were identified as statin-users. During 11,963,322 person-years (PY) of follow-up, a total of 86,018 incident stroke events occurred (719.0 events per 100,000 PYs). Compared to statin non-user exposed to high level of PM10 (>50 µg/m3) and PM2.5 (>25 µg/m3), statin users had 20% (adjusted hazard ratio [HR], 0.80; 95% confidence intervals [CI], 0.75 to 0.85) and 17% (adjusted HR, 0.80; 95% CI, 0.80 to 0.86) lower adjusted risk of incident stroke for PM10 and PM2.5, respectively. Similar risk reduction for incident CVD was also found among statin-users exposed to low or moderate level of PM10 (≤50 µg/m3) and PM2.5 (≤25 µg/m3) exposure.

CONCLUSION

Among adults aged 60 years and older with high and low or moderate levels of exposure to PM10 and PM2.5, statin use was associated with a significantly lower risk of stroke.

Timing of clinic visits after health checks and risk of hospitalization for cardiovascular events and all-cause death among the high-risk population

BACKGROUND AND AIMS

We aimed to examine the association between timing of clinic visits after health checks and risk of hospitalization for cardiovascular events and all-cause mortality among the high-risk population.

METHODS

A total of 412,059 high-risk individuals from the health claims database of the Japan Health Insurance Association were divided into 4 groups according to the timing of clinic visits during 12 months after health checks (early: <3 months, intermediate: 4-6 months, late: 7-12 months, and none). Cox proportional hazard regression models were used to examine the associations between timing of clinic visits after health checks and risk of hospitalization for stroke, coronary heart disease, heart failure, or all-cause mortality.

RESULTS

During a median follow-up of 4.3 years, we identified a total of 15,860 cases having composite outcomes of first hospitalization for stroke, coronary heart disease, heart failure, or all-cause mortality. Compared to high-risk adults without clinic visits after the health checks, the fully adjusted hazard ratios (95% confidence interval) of a composite outcome were 0.78 (0.74, 0.81), 0.84 (0.78, 0.89), and 0.94 (0.89, 1.00) for early, intermediate, and late clinic visits, respectively. Compared to no clinic visit, an early clinic visit was associated with lower risks of all individual endpoints, and the risk reductions appeared to be greater in the hospitalization for stroke and heart failure.

CONCLUSIONS

The present study using real-world data provided evidence that an early clinic visit after health checks was associated with lower risks of hospitalization for major cardiovascular events and all-cause mortality among high-risk individuals.

Landscape of Statin as a Cornerstone in Atherosclerotic Cardiovascular Disease

Atherosclerosis, the key pathogenesis of cardiovascular disease, is a leading cause of death and disability worldwide. Statins are first-line lipid-lowering drugs, which have been demonstrated to be powerful agents for anti-atherosclerosis. Numerous studies have confirmed the cardiovascular benefits and long-term safety of statins in a wide range of patients. Statins play an indispensable and irreplaceable part in the prevention and treatment of atherosclerotic cardiovascular disease (ASCVD). In this article, we summarize the evolution of statins and their role in the treatment of cholesterol. The anti-atherosclerotic mechanism of statins, its efficacy, safety and clinical outcomes in secondary and primary prevention of ACSVD in different patient populations, the combination treatment effects, and guideline recommendations are also detailed. This paper highlights the profound significance of statins as the most successful anti-atherogenic drug in the cardiovascular field.

Management of Coronary Artery Disease in Older Adults: Recent Advances and Gaps in Evidence

Coronary artery disease (CAD) is highly prevalent in older adults, yet its management remains challenging. Treatment choices are made complex by the frailty burden of older patients, a high prevalence of comorbidities and body composition abnormalities (e.g., sarcopenia), the complexity of coronary anatomy, and the frequent presence of multivessel disease, as well as the coexistence of major ischemic and bleeding risk factors. Recent randomized clinical trials and epidemiological studies have provided new data on optimal management of complex patients with CAD. However, frail older adults are still underrepresented in the literature. This narrative review aims to highlight the importance of assessing frailty as an aid to guide therapeutic decision-making and tailor CAD management to the specific needs of older adults, taking into account age-related pharmacokinetic and pharmacodynamic changes, polypharmacy, and potential drug interactions. We also discuss gaps in the evidence and offer perspectives on how best in the future to optimize the global strategy of CAD management in older adults.

In-Hospital Mortality and Its Predictors among Hospitalized Diabetes Patients: A Prospective Observational Study

Background. Diabetes mellitus (DM) is one of the leading health emergencies of the 21st century and among the top ten causes of death among adults globally in 2017. Although Ethiopia has been victimized by the growing prevalence of DM, data regarding in-hospital mortality among admitted diabetic patients in Ethiopia, specifically in Jimma Medical Center (JMC), are lacking. Objective. The aim of the study is to assess in-hospital mortality and its predictors among DM patients admitted to Jimma Medical Center. Methods. A hospital-based prospective observational study was employed involving 120 diabetes patients admitted to JMC from October 01, 2020, to June 30, 2021. Data were collected on variables related to the patient, disease, medication, and clinical outcomes. Data were entered into Epidata version 4.6.0.4 for cleaning and exported to SPSS version 23.0 for analysis. Kaplan–Mayer and cox-regression analyses were used to compare the survival experience and to determine the predictors of clinical outcomes, respectively. Hazard ratio with its two-sided $p$ value <0.05 was considered to declare the statistical significance. Result. Of 120 DM patients, 81 (67.5%) of them were males. The in-hospital mortality was 13.34% (16/120). Rural residence (AHR: 3.46; 95% CI (1.12, 9.81)), age (AHR: 1.03; 95% CI: (1.001, 1.059)), admission with diabetic ketoacidosis (AHR: 5.01; 95% CI (1.12, 21.88)), and multiple comorbidities: five comorbidities (AHR: 9.65; 95% CI (1.07, 19.59)) and six comorbidities (AHR: 14.02; 95% CI (1.74, 21.05)) were independently associated with in-hospital mortality. On the other hand, exposure to nonantidiabetic medications decreased the hazard of mortality by 86.5% (AHR: 0.135; 95% CI (0.04, 0.457)). Conclusion. This study showed the rate of in-hospital mortality was noticeably high. The study showed that rural residence, age, DKA, and having comorbidities (five and six) were the statistically significant predictors of in-hospital mortality. In contrast, the use of nonantidiabetic medications such as statins, ASA, and other antihypertensive agents before admission remained protective. Thus, proper strategies have to be devised to improve in-hospital mortality among admitted DM patients.

Coronary artery calcification on routine CT has prognostic and treatment implications for all ages

AIMS

Guidelines have recommended reporting coronary artery calcification (CAC) if present on chest CT imaging regardless of indication. This study assessed CAC prevalence, prognosis and the potential clinical impact of its reporting.

METHODS

We performed a single-centre retrospective analysis (January-December 2015) of 1400 chest CTs (200 consecutive within each age group: <40, 40-49, 50-59, 60-69, 70-79, 80-89, ≥90). CTs were re-reviewed for CAC presence and severity and excluded if prior coronary intervention. Comorbidities, statin prescription and clinical outcomes (myocardial infarction [MI], stroke, all-cause mortality) were recorded. The impact of reporting CAC was assessed against pre-existing statin prescriptions.

RESULTS

1343 patients were included (mean age 63±20 years, 56% female). Inter- and intra-observer variability for CAC presence at re-review was almost perfect (κ 0.89, p < 0.001; κ 0.90, p < 0.001) and for CAC grading was substantial and almost perfect (κ 0.68, p < 0.001; κ 0.91, p < 0.001). CAC was observed in 729/1343 (54%), more frequently in males (p < 0.001) and rising age (p < 0.001). A high proportion of patients with CAC in all age groups had no prior statin prescription (range: 42% [80-89] to 100% [<40]). The 'number needed to report' CAC presence to potentially impact management across all ages was 2. 689 (51%) patients died (median follow-up 74-months). CAC presence was associated with risk of MI, stroke and all-cause mortality (p < 0.001). After adjusting for confounders, severe calcification predicted risk of all-cause mortality (HR 1.8 [1.2-2.5], p = 0.002).

CONCLUSION

Grading of CAC was reproducible, and although prevalence rose with age, prognostic and treatment implications were maintained in all ages.

Effectiveness of statins for the primary prevention of cardiovascular disease in the Asian elderly population

BACKGROUND

Population aging is a global trend, and the elderly have a higher risk of atherosclerotic cardiovascular disease (ASCVD) and related mortality. Statins have been observed to reduce cardiovascular events in patients with ASCVD. However, compared with secondary prevention, the benefits of statins for primary prevention are undetermined among the elderly.

AIMS

This study aimed to evaluate the effectiveness of statins in an elderly population without a history of cardiovascular disease (CVD).

METHODS

The study was carried out using the National Taiwan University Hospital Integrated Medical Database and the National Health Insurance Research Database in Taiwan. Patients aged 65 years and older without a history of CVD were identified between 1 February 2008 and 31 December 2015. New statin users were 1:4 matched to nonusers based on certain variables. The risks of major adverse cardiovascular events (MACEs) and all-cause mortality were estimated using Cox proportional hazards models. Further, we applied marginal structural models to account for time-varying low-density lipoprotein cholesterol (LDL-C) levels.

RESULTS

A total of 2761 new statin users and 9503 nonusers were selected after matching; the mean age was 71.8 years, and 63% were women. At a median follow-up of 4.8 years, statin use was associated with reduced risk of MACEs (hazard ratio [HR]: 0.75; 95% confidence interval [CI], 0.52-0.98) and mortality (HR: 0.72, 95% CI: 0.55-0.93) when accounting for time-varying LDL-C. No significant differences in effect were detected between subgroups.

CONCLUSION

Statin use could be beneficial for the primary prevention of CVD in elderly Asians.

Factors Associated with Discontinuation of Statin Therapy in Patients with Lymphoma Aged 80 Years and Older: A Retrospective Single-Institute Study

Background

There is little evidence to support or negate the benefits of statin therapy for primary prevention of cardiovascular disease (CVD) in lymphoma patients aged 80 years or older.

Objective

We evaluated comprehensive geriatric assessment (CGA) scores and previously reported risk factors for failure of statin therapy discontinuation in lymphoma patients aged 80 years and older with the aim of identifying those in whom discontinuation of statins for primary CVD prevention is indicated.

Patients and methods

Our study cohort comprised 50 patients aged 80 years and older treated with chemotherapy for lymphoma at our institute from January 2011 to July 2020. We retrospectively analyzed the associations between CGA, including Geriatric 8, instrumental activities of daily living, and Charlson comorbidity index, and previously reported factors associated with failure of statin therapy discontinuation, defined as reintroduction of statins after their discontinuation, in this patient cohort.

Results

Twenty years or less of statin therapy was an independent predictor of failure of statin therapy discontinuation (hazard ratio 8.240, 95% confidence interval 1.380–49.10). There were significant differences in the rate of failure of statin discontinuation between patients receiving statins for ≥ 20 years versus < 20 years (p = 0.010). Multivariate analysis of CGA-related scores identified no significant risk factors for failure of statin discontinuation.

Conclusions

Discontinuation of statin therapy may be indicated in lymphoma patients aged 80 years and older who have used statins for 20 years or more.

Development, validation, and visualization of a web-based nomogram to predict 5-year mortality risk in older adults with hypertension

Background

Hypertension-related mortality has been increasing in older adults, resulting in serious burden to society and individual. However, how to identify older adults with hypertension at high-risk mortality remains a great challenge. The purpose of this study is to develop and validate the prediction nomogram for 5-year all-cause mortality in older adults with hypertension.

Methods

Data were extracted from National Health and Nutrition Examination Survey (NHANES). We recruited 2691 participants aged 65 years and over with hypertension in the NHANES 1999-2006 cycles (training cohort) and 1737 participants in the NHANES 2007-2010 cycles (validation cohort). The cohorts were selected to provide at least 5 years follow-up for evaluating all-cause mortality by linking National Death Index through December 31, 2015. We developed a web-based dynamic nomogram for predicting 5-year risk of all-cause mortality based on a logistic regression model in training cohort. We conducted internal validation by 1000 bootstrapping resamples and external validation in validation cohort. The discrimination and calibration of nomogram were evaluated using concordance index (C-index) and calibration curves.

Results

The final model included eleven independent predictors: age, sex, diabetes, cardiovascular disease, body mass index, smoking, lipid-lowering drugs, systolic blood pressure, hemoglobin, albumin, and blood urea nitrogen. The C-index of model in training and validation cohort were 0.759 (bootstrap-corrected C-index 0.750) and 0.740, respectively. The calibration curves also indicated that the model had satisfactory consistence in two cohorts. A web-based nomogram was established (https://hrzhang1993.shinyapps.io/dynnomapp).

Conclusions

The novel developed nomogram is a useful tool to accurately predict 5-year all-cause mortality in older adults with hypertension, and can provide valuable information to make individualized intervention.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03087-3.

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.

Cardiovascular Risk Factors and Physical Activity for the Prevention of Cardiovascular Diseases in the Elderly

Cardiovascular diseases create an important burden on the public health systems, especially in the elderly, mostly because this group of patients frequently suffer from multiple comorbidities. Accumulating cardiovascular risk factors during their lifetime has a detrimental effect on an older adult's health status. The modifiable and non-modifiable cardiovascular risk factors are very diverse, and are frequently in a close relationship with the metabolic comorbidities of the elderly, mainly obesity and Diabetes Mellitus. In this review, we aim to present the most important cardiovascular risk factors which link aging and cardiovascular diseases, starting from the pathophysiological links between these factors and the aging process. Next, we will further review the main interconnections between obesity and Diabetes Mellitus and cardiovascular diseases of the elderly. Lastly, we consider the most important aspects related to prevention through lifestyle changes and physical activity on the occurrence of cardiovascular diseases in the elderly.

The association of apolipoproteins with later-life all-cause and cardiovascular mortality: a population-based study stratified by age

Midlife lipid levels are important predictors of cardiovascular diseases, yet their association with mortality in older adults is less clear. We aimed to (1) identify lipid profiles based on cholesterol, triglycerides, and apolipoproteins using cluster analysis, and (2) investigate how lipid profiles and lipid levels at different ages are associated with later-life all-cause and cardiovascular mortality. We used data from 98,270 individuals in the Swedish AMORIS cohort who had blood measurements between 1985-1996 and were followed until 2012. Over the follow-up (mean 18.0 years), 30,730 (31.3%) individuals died. Three lipid profiles were identified. Compared with reference profile, a high lipid profile (low ApoA-I and high total cholesterol (TC), triglycerides, ApoB, and ApoB/ApoA-I ratio) at ages 39-59 or 60-79 was associated with higher all-cause mortality. A high lipid profile at ≥ 80 years, however, did not confer higher mortality. For the specific markers, high TC (≥ 7.25 mmol/L) was associated with higher all-cause mortality in ages 39-59 but lower mortality in ages 60-79 and ≥ 80. Low ApoA-I (< 1.28 g/L) and high ApoB/ApoA-I ratio (≥ 1.18), on the other hand, were associated with higher cardiovascular mortality regardless of age at lipid measurement, highlighting their potential relevance for survival in both young and older individuals.

Statin Therapy in Very Old Patients: Lights and Shadows

Atherosclerotic cardiovascular diseases (ASCVD) are the leading cause of death worldwide. High levels of total cholesterol—and of low-density lipoprotein cholesterol in particular—are one of the main risk factors associated with ASCVD. Statins are first-line treatment for hypercholesterolemia and have been proven to reduce major vascular events in adults with and without underlying ASCVD. Findings in the literature show that statins reduce coronary and cerebrovascular morbidity and mortality in middle-aged people, but their benefits in older adults are not as well-established, especially in primary prevention. Furthermore, many particularities must be considered regarding their use in old subjects, such as age-related changes in pharmacokinetics and pharmacodynamics, comorbidities, polypharmacy, and frailty, which decrease the safety and efficacy of statins in this population. Myopathy and a possible higher risk of falling along with cognitive decline are classic concerns for physicians when considering statin use in the very old. Additionally, some studies suggest that the relative risk for coronary events and cardiovascular mortality associated with high levels of cholesterol decreases after age 70, making the role of statins unclear. On the other hand, ASCVD are one of the most important causes of disability in old subjects, so cardiovascular prevention is of particular interest in this population in order to preserve functional status. This review aims to gather the current available evidence on the efficacy and safety of statin use in very old patients in both primary and secondary prevention.

PoLA/CFPiP/PCS/PSLD/PSD/PSH guidelines on diagnosis and therapy of lipid disorders in Poland 2021

In Poland there are still nearly 20 million individuals with hypercholesterolaemia, most of them are unaware of their condition; that is also why only ca. 5% of patients with familial hypercholesterolaemia have been diagnosed; that is why other rare cholesterol metabolism disorders are so rarely diagnosed in Poland. Let us hope that these guidelines, being an effect of work of experts representing 6 main scientific societies, as well as the network of PoLA lipid centers being a part of the EAS lipid centers, certification of lipidologists by PoLA, or the growing number of centers for rare diseases, with a network planned by the Ministry of Health, improvements in coordinated care for patients after myocardial infarction (KOS-Zawał), reimbursement of innovative agents, as well as introduction in Poland of an effective primary prevention program, will make improvement in relation to these unmet needs in diagnostics and treatment of lipid disorders possible.

Association of chronic venous disease with major adverse cardiovascular events

OBJECTIVE

The aim of the present study was to examine whether severe chronic venous disease (CVD) is associated with a greater risk of major adverse cardiovascular events (MACE) compared with mild CVD.

METHODS

Participants with CVD were prospectively recruited from outpatient vascular departments at two hospitals in North Queensland, Australia. CVD severity was ascertained by vascular specialists using the CEAP (clinical, etiologic, anatomic, pathophysiologic) classification. MACE, defined as myocardial infarction, stroke, or cardiovascular death, were identified from the outpatient follow-up and linked medical records. Kaplan-Meier and Cox proportional hazard analyses were used to examine the association of CVD severity with the occurrence of MACE. A subanalysis was performed in which participants with CEAP C5 and C6 (severe CVD) were compared with those with CEAP C2 to C4 (mild CVD).

RESULTS

A total of 774 participants were included and followed up for a median of 3.09 years (interquartile range, 1.09-8.14 years). The participants with C6 CVD (n = 69) had a threefold greater risk of MACE (hazard ratio, 3.03; 95% confidence interval, 1.02-9.03; P = .046) compared with those with C2 CVD (n = 326) after adjusting for other risk factors. Participants with severe CVD had an increased risk of MACE compared with those with mild CVD (adjusted hazard ratio, 2.37; 95% confidence interval, 1.12-5.04; P = .024).

CONCLUSIONS

Individuals with severe CVD have an increased risk of MACE compared with those with mild CVD, independently of traditional risk factors. Further research is required to clarify the cause of the excess risk.