Statin therapy in the elderly: does it make good clinical and economic sense?

Primary Prevention of Coronary Heart Disease in the Elderly

OBJECTIVE:

To review relevant literature supporting the use of antihypertensive agents, lipid-lowering agents (i.e., statins), and aspirin therapy for the primary prevention of coronary heart disease (CHD) in an elderly patient population (age ≥65 y).

DATA SOURCES:

A MEDLINE search (1988–January 2003) was conducted.

STUDY SELECTION AND DATA EXTRACTION:

Primary and tertiary literature involving the uses of antihypertensives, statins, and aspirin therapy in the elderly were reviewed.

DATA SYNTHESIS:

Mortality due to CHD in the US population has decreased 40–50% over the last 30 years; however, CHD remains the leading cause of morbidity and mortality in elderly persons. As the population continues to age, the number of older adults eligible for primary prevention will rise. The American Heart Association clinical practice guidelines for the primary prevention of CHD were updated in 2002; however, they are based on findings from clinical trials that enrolled predominantly middle-aged white men. The recommendations for elderly individuals are predominantly extrapolated from subgroup analyses of randomized clinical trials or cohort studies. This literature suggests that elderly persons are candidates for primary prevention measures and experience reductions in coronary events when treated with appropriate therapies.

CONCLUSIONS:

Data suggest that use of antihypertensives, statins, and aspirin therapy in the elderly appears effective to an extent similar to, and often greater than, that observed in younger patients. We believe these agents should be prescribed to all appropriate high-risk elderly patients. Ongoing and future studies will more clearly elucidate the benefits of primary prevention therapy, particularly in persons ≥75 years of age.

Pharmacoeconomics and aging

The aging of the general population in industrialized countries has brought to public attention the increasing incidence of age-related clinical conditions, because the long-term impact of diseases on functional status and on costs are greater in older people than in any other age group. With the aging of the population, it is becoming increasingly important to quantify the burden of illness in the elderly; this will be vital not only in planning for the necessary health services that will be required in coming years, but also in order to measure the benefit to be expected from interventions to prevent disability in older people. The management of multiple and chronic disorders has become a more important issue for healthcare authorities because of increasing requests for medical assistance and healthcare interventions. Among these, pharmacological treatments and drug utilization in older people are pressing issues for healthcare managers and politicians; indeed, a relatively small proportion of the population accounts for a substantial part of public drug costs. Two key sources of pressure are well known: the growing number of elderly persons, who are the highest per-capita users of medicines, and the introduction of new, often more expensive, medicines. On the other hand, the development of strategies for controlling costs, while providing the elderly with equitable access to needed pharmaceuticals, should be based on an evaluation of the economic impact of pharmacological care in older people, taking into account the burden of illness, drug utilization data, drug technology assessment evidence and results. Furthermore, there are major factors affecting pharmacological care in older people: for example inappropriate prescribing, lack of adherence and compliance, and the burden of adverse drug events. The assessment of these factors should be considered a priority in pharmacoeconomic evaluations in the aging population, and the most relevant evidence will be reviewed in this paper with examples referring to particular settings or conditions and diseases, such as the presence of cardiovascular risk factors, diabetes and chronic pain.

Promoting cardiovascular health: special considerations for the elderly

Although clinicians and researchers understand the need to promote cardiovascular health in people of all ages, with population aging there are particular insights/issues that should be considered when counseling and caring for elderly patients. The focus here is to present current statistics relative to aging in the United States, discuss risk factors and lifestyle with a particular focus on those 65 years and older, and further discuss the need to continuously monitor activities of daily living and instrumental activities of daily living in elderly persons to ensure that whatever is done to promote cardiovascular health does not interfere with functional independence.

Hyperlipidemia in the elderly

People are now living longer, largely because of a combination of falling rates of fertility and mortality, thus producing a greater proportion of older people in society. Thirty times more centenarians were alive in 2000 than in 1900, and the population growth in the elderly segment of society is expected to continue at an exponential rate. Vascular disease is responsible for more than a quarter of all deaths worldwide. More than 80% of individuals who die of coronary heart disease are older than 65 years. Although a myocardial infarction may be perceived as fatal, heart attacks do not always lead to death but to conditions such as congestive heart failure, ischemic cardiomyopathy, and angina, which greatly impact quality of life. These issues are only a few that must be contemplated when considering the clinical and economic effects of preventive therapies in the elderly population.

Children of persons with Alzheimer disease: what does the future hold?

Children of persons with Alzheimer disease (AD), as a group, face an increased risk of developing AD. Many of them, throughout their adult lives, seek input on how to reduce their chances of one day suffering their parent's fate. We examine the state of knowledge with respect to risk and protective factors for AD and recommend a research agenda with special emphasis on AD offspring.

Statins for the primary prevention of cardiovascular events in older adults: a review of the evidence

BACKGROUND

Although statins have been demonstrated to be beneficial for secondary prevention in the elderly, their use for primary prevention has not been well described.

OBJECTIVE

In this review, we summarize data regarding the efficacy, safety, and current recommendations for statins for the primary prevention of cardiovascular events in older adults.

METHODS

This review is based on a computerized literature search of the PubMed database for articles published in the English language from January 1980 to June 2006. Key words searched individually and cross-referenced included: statins, HMG-CoA reductase inhibitors, cholesterol, elderly, aged, cardiovascular disease, primary prevention, risk stratification, and C-reactive protein. This search produced 445 citations; reference lists revealed an additional 12 citations, all of which were screened for relevance to the topic.

RESULTS

The existing evidence suggests, but does not confirm, benefit from the use of statins for primary prevention in the elderly subgroup (ie, those aged >65 years). Of the 6 published trials of statins for primary prevention, only 3 included subjects aged >75 years, and subgroup results in older adults are unavailable. Current guidelines recommend statins for individuals based on their assessed cardiovascular risk.

CONCLUSIONS

Extension of treatment guidelines should consider an individual's global risk of coronary heart disease. However, due to the prevalence of subclinical disease in older adults, risk may be higher or otherwise differ with age. In addition, tolerance for and barriers to adherence with long-term medical therapy are important treatment considerations in older adults. Prospective, randomized controlled trials that better define the tolerability, safety, and efficacy of statin therapy in older adults with elevated cholesterol levels and intermediate cardiovascular risk are needed.

Comparison of the lipid-modifying efficacy and safety profiles of ezetimibe coadministered with simvastatin in older versus younger patients with primary hypercholesterolemia: A post Hoc analysis of subpopulations from three pooled clinical trials

BACKGROUND

Despite the need for effective and well-tolerated lipid-lowering therapies for primary hypercholesterolemia in older patients, there is a relative paucity of published data on such treatments in this population.

OBJECTIVE

We conducted a post hoc analysis to examine the lipid-modifying efficacy and safety profile of simvastatin (SIMVA) monotherapy, and the coadministration of ezetimibe (EZE) and SIMVA (EZE/SIMVA) in older (ie, aged>or=65 years) versus younger (ie, aged<65 years) patients with primary hypercholesterolemia.

METHODS

We analyzed pooled data from 3 previously published, similarly designed, randomized, double-blind, placebo-controlled studies in patients with primary hypercholesterolemia. After a 6- to 8-week washout, a 4-week dietary stabilization period, and a 4-week placebo run-in period, patients with low-density lipoprotein cholesterol (LDL-C) of 145 to 250 mg/dL were randomized to EZE/SIMVA 10/10, 10/20, 10/40, or 10/80 mg; SIMVA 10, 20, 40, or 80 mg; EZE 10 mg; or placebo for 12 weeks. In this post hoc analysis, the percent change from baseline to week 12 in LDL-C, high-density lipoprotein cholesterol (HDL-C), non-HDL-C, apolipoprotein B (apo B), triglycerides (TG), and high-sensitivity C-reactive protein (hs-CRP) for EZE/SIMVA (pooled across doses) versus SIMVA alone (pooled across doses) was compared between older and younger patients with primary hypercholesterolemia. Tolerability was assessed by adverse event reports and laboratory and vital signs assessments throughout the study.

RESULTS

A total of 3083 patients aged 20 to 87 years were included in the 3 studies (2320 were aged<65 years and 763 were aged>or=65 years). Baseline lipid values and patient characteristics were similar among all treatment groups for patients aged<65 years versus those aged>or=65 years except that there was a higher percentage of females (62% vs 50%) and patients with hypertension (46% vs 29%) in the older versus younger subgroup (both, P<0.001). EZE/SIMVA was associated with greater improvements than SIMVA alone in LDL-C, non-HDL-C, apo B, TG, and hs-CRP (all, P<0.001); these effects did not appear to differ between the older and younger sub-groups (all, P=NS). Changes in HDL-C did not differ significantly between the EZE/SIMVA and SIMVA groups. More patients receiving EZE/SIMVA than SIMVA monotherapy achieved the target LDL-C level<100 mg/dL (P<0.001), regardless of age subgroup (77% vs 41% for patients aged<65 years and 85% vs 48% for patients aged>or=65 years). In the younger sub-group, the incidence of creatinine phosphokinase (CK) elevations>or=10x the upper limit of normal (ULN) was <I% in the placebo, SIMVA, and EZE/SIMVA groups and 0% in the EZE group; in the older subgroup, no CK elevations>or=10x ULN were reported. In younger patients, the incidence of consecutive alanine amino-transferase or aspartate aminotransferase levels>or=3x ULN was 0% for placebo and EZE, <1% for SIMVA, and 2% for EZE/SIMVA; in older patients, it was 1% for placebo and EZE, <1% for SIMVA, and 0% for EZE/SIMVA.

CONCLUSION

This post hoc analysis of pooled data from 3 previously published large clinical trials suggests that EZE/SIMVA was well tolerated and associated with improved lipid profiles in both older and younger patients with primary hypercholesterolemia.

Drug Insight: statin use in the elderly

The elderly represent a notable proportion of patients who present with myocardial infarction or acute coronary syndromes. This subgroup of patients also experiences a higher incidence of adverse outcomes than younger age-groups, and, therefore, has more to gain from effective, evidence-based therapies. The efficacy of statins in secondary cardiovascular disease prevention is firmly established. The starting of therapy soon after an acute coronary event has been shown to provide added benefit. Uncertainties about the effectiveness of statins in the elderly, however, have resulted in their underuse in this population. In this review we evaluate the evidence for statin use in this important and increasingly large group of patients.

Quelle signification pour le taux de cholestérol après 75 ans?

Increasing comorbidity with aging reduces the predictive power of cardiovascular risk factors. From the age of 70 onward, total cholesterol levels decrease, perhaps associated with changes in the composition of some lipoprotein fractions. In subjects older than 75 years, being in the lowest quartile of cholesterol, insulinemia or serum albumin concentrations is associated with increased mortality. Cholesterol levels below 189 mg/dL in subjects older than 75 years should be considered an early sign of unidentified comorbidity or of rapid functional decline. HDL cholesterol levels, rather than total or LDL cholesterol, were inversely associated with increased mortality from ischemic coronary disease and stroke appears to rise as HDL cholesterol levels fall, rather than total or LDL cholesterol. On the other hand, LDL concentrations below 106 mg/dL and HDL concentrations below 36 mg/dL were associated with an increased risk of death from infectious disease. Stroke incidence, in particular, ischemic stroke, is highest in subjects older than 75 years. HDL cholesterol levels above 35 mg/dL appear to have a protective effect against ischemic stroke in subjects younger than 70 years. Two interventional drug studies investigating the effects of two statins (simvastatin and pravastatin) found that in subgroups of subjects older than 75 these drugs were associated with a reduction in all-cause mortality and cardiovascular morbidity, regardless of total cholesterol levels, but had no short-term effect on cognitive function.

Efficacy and safety of coadministration of ezetimibe and statins in elderly patients with primary hypercholesterolaemia

OBJECTIVE

To compare the efficacy and safety of statin (HMG-CoA reductase inhibitor) monotherapy versus ezetimibe 10mg plus statin in older and younger adults with primary hypercholesterolaemia.

PATIENTS AND METHODS

Four multicentre, randomised, double-blind, placebo-controlled, balanced parallel-group trials were pooled for analysis. After washout and placebo run-in period, men and women >/=18 years of age (n = 1861) with primary hypercholesterolaemia (plasma low-density lipoprotein-cholesterol [LDL-C] level from >/=3.76 to </=6.48 mmol/L and triglycerides </=3.95 mmol/L) were randomised to either placebo, statin monotherapy (lovastatin or pravastatin 10, 20 or 40 mg, simvastatin or atorvastatin 10, 20, 40 or 80 mg) or ezetimibe plus statin for 12 weeks. For each study, the primary efficacy endpoint was the percentage reduction in LDL-C from baseline to study endpoint. In the present study, age subset analyses on data pooled across these four trials were carried out to determine whether coadministration of ezetimibe and statin was equally efficacious across specific age groupings: age <65 versus >/=65 years; age <75 versus >/=75 years.

RESULTS

Across age groupings, coadministration of ezetimibe and statin produced significant incremental reductions in LDL-C compared with statin monotherapy. The beneficial effects of ezetimibe plus statin on LDL-C, triglycerides and high-density lipoprotein-cholesterol (HDL-C) were overall independent of age groupings. Ezetimibe plus statin therapy was generally well tolerated, with similar incidence of adverse events, serious adverse events and changes in liver function and muscle enzymes in the given age groups compared with statin therapy alone.

CONCLUSION

The beneficial effects of ezetimibe coadministered with statins on LDL-C, triglycerides and HDL-C were similar between older and younger hypercholesterolaemic patients, with a favourable safety profile across all patient age groups.

Risk factors for atherosclerotic vascular disease

Several controlled interventional trials have shown the benefit of anti-hypertensive and hypolipidaemic drugs for the prevention of coronary heart disease (CHD). International guidelines for the prevention of CHD agree in their recommendations for tertiary prevention and recommend lowering the blood pressure to below 140 mm/90 mm Hg and low density lipoprotein (LDL)-cholesterol to below 2.6 mmol/l in patients with manifest CHD. Novel recommendations for secondary prevention are focused on the treatment of the pre-symptomatic high-risk patient with an estimated CHD morbidity risk of higher than 20% per 10 years or an estimated CHD mortality risk of higher than 5% per 10 years. For the calculation of this risk, the physician must record the following risk factors: sex, age, family history of premature myocardial infarction, smoking, diabetes, blood pressure, total cholesterol, LDL-cholesterol, high-density lipoprotein (HDL)-cholesterol, and triglyceride. This information allows the absolute risk of myocardial infarction to be computed by using scores or algorithms which have been deduced from results of epidemiological studies. To improve risk prediction and to identify new targets for intervention, novel risk factors are sought. High plasma levels of C-reactive protein has been shown to improve the prognostic value of global risk estimates obtained by the combination of conventional risk factors and may influence treatment decisions in patients with intermediate global cardiovascular risk (CHD morbidity risk of 10%-20% per 10 years or CHD mortality risk of 2%-5% per 10 years).

Statin therapy in the elderly

PURPOSE OF REVIEW

The clinical efficacy and safety of statin therapy have been well established from a series of large-scale, randomized controlled trials. These trials, however, have predominantly recruited patients under the age of 70 years. As a consequence, the use of statins in older patients has remained controversial.

RECENT FINDINGS

The results of the first trial to look exclusively at the elderly--the Prospective Study of Pravastatin in the Elderly at Risk--have added enormously to our understanding of the use of statins in the elderly. These findings, together with those from the large elderly cohort within the Heart Protection Study and the smaller elderly subgroups within the other major statin trials, have forced us to re-evaluate any systematic exclusion of elderly patients from statin therapy.

SUMMARY

The collective evidence now strongly supports the use of statins in the at-risk elderly population.