Should we identify and treat hyperlipidemia in the advanced elderly?

Krupa Shah, John Rogers, Denise Britigan

Research output: Contribution to journalReview article

2 Citations (Scopus)

Abstract

CAD is the leading cause of death in the United States and is a significant cause of mortality and morbidity for those aged 65 years and older. Multiple studies have demonstrated the value of lipid-lowering therapy for the primary and secondary prevention of CAD. Most of these studies have not been specifically oriented toward the elderly; however, substantial data from subgroup analyses of older subjects from major lipid treatment trials has consistently demonstrated the beneficial effects of statin therapy in reducing all cardiovascular events for patients with known CAD who are 65 and older. Unfortunately, randomized trials of hyperlipidemia treatment with statins have enrolled few people aged 80 and above. Hence, it is unclear whether the benefit of statins on cardiovascular mortality extends to advanced elderly patients. These people comprise the fastest-growing segment of the population, increasing by about 3% per year. They tend to experience concomitant chronic illness, shorter life expectancy, and physical frailty, leading to quality-of-life and end-of-life issues. Is it beneficial and cost-effective to treat these very elderly patients for hyperlipidemia? The first prospective, randomized trial of the use of statins among the elderly examined the impact of pravastatin therapy on primary and secondary prevention of cardiovascular and cerebrovascular events for men and women (age 70-82 years), with a history of vascular disease or with risk factors for vascular disease. The sample of 5804 participants was randomized to receive pravastatin 40 mg or placebo, followed for an average of 3.2 years, and monitored for the combined endpoint of myocardial infarction (MI), stroke, and CAD death. The study showed 19% (95% confidence interval [CI], 6-31; P=.006) proportional reduction in the rate of coronary death or nonfatal MI. The absolute risk reduction for coronary death or nonfatal myocardial infarction or nonfatal stroke was significant (2.2%, number needed to treat [NNT]=45). Rates of adverse drug events were similar in the intervention and control groups. Serum cholesterol normally declines with age; so the benefit of lowering lipids with medication in this age group is unclear. Furthermore, a meta-analysis showed an inverse relationship between total serum cholesterol and all-cause mortality for people aged 80 and above, raising the possibility that lowering cholesterol may be detrimental in this age group. Two other cohort studies found that low cholesterol was related to all-cause mortality, even when adjusted for health status and indicators of frailty. The reasons for this relationship are not clear, but some postulated mechanisms exist. It is possible that lower cholesterol levels can increase the risk of a variety of nonatherosclerotic diseases since cholesterol may play a direct role in immune response. Alternatively, preclinical diseases, chronic inflammation, or malnutrition may suppress cholesterol levels.

Original languageEnglish (US)
Pages (from-to)356-357
Number of pages2
JournalJournal of Family Practice
Volume55
Issue number4
StatePublished - Apr 1 2006

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Hyperlipidemias
Hydroxymethylglutaryl-CoA Reductase Inhibitors
Cholesterol
Mortality
Pravastatin
Numbers Needed To Treat
Myocardial Infarction
Primary Prevention
Secondary Prevention
Vascular Diseases
Lipids
Chronic Disease
Age Groups
Stroke
Health Status Indicators
Therapeutics
Life Expectancy
Drug-Related Side Effects and Adverse Reactions
Serum
Malnutrition

ASJC Scopus subject areas

  • Family Practice

Cite this

Should we identify and treat hyperlipidemia in the advanced elderly? / Shah, Krupa; Rogers, John; Britigan, Denise.

In: Journal of Family Practice, Vol. 55, No. 4, 01.04.2006, p. 356-357.

Research output: Contribution to journalReview article

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abstract = "CAD is the leading cause of death in the United States and is a significant cause of mortality and morbidity for those aged 65 years and older. Multiple studies have demonstrated the value of lipid-lowering therapy for the primary and secondary prevention of CAD. Most of these studies have not been specifically oriented toward the elderly; however, substantial data from subgroup analyses of older subjects from major lipid treatment trials has consistently demonstrated the beneficial effects of statin therapy in reducing all cardiovascular events for patients with known CAD who are 65 and older. Unfortunately, randomized trials of hyperlipidemia treatment with statins have enrolled few people aged 80 and above. Hence, it is unclear whether the benefit of statins on cardiovascular mortality extends to advanced elderly patients. These people comprise the fastest-growing segment of the population, increasing by about 3{\%} per year. They tend to experience concomitant chronic illness, shorter life expectancy, and physical frailty, leading to quality-of-life and end-of-life issues. Is it beneficial and cost-effective to treat these very elderly patients for hyperlipidemia? The first prospective, randomized trial of the use of statins among the elderly examined the impact of pravastatin therapy on primary and secondary prevention of cardiovascular and cerebrovascular events for men and women (age 70-82 years), with a history of vascular disease or with risk factors for vascular disease. The sample of 5804 participants was randomized to receive pravastatin 40 mg or placebo, followed for an average of 3.2 years, and monitored for the combined endpoint of myocardial infarction (MI), stroke, and CAD death. The study showed 19{\%} (95{\%} confidence interval [CI], 6-31; P=.006) proportional reduction in the rate of coronary death or nonfatal MI. The absolute risk reduction for coronary death or nonfatal myocardial infarction or nonfatal stroke was significant (2.2{\%}, number needed to treat [NNT]=45). Rates of adverse drug events were similar in the intervention and control groups. Serum cholesterol normally declines with age; so the benefit of lowering lipids with medication in this age group is unclear. Furthermore, a meta-analysis showed an inverse relationship between total serum cholesterol and all-cause mortality for people aged 80 and above, raising the possibility that lowering cholesterol may be detrimental in this age group. Two other cohort studies found that low cholesterol was related to all-cause mortality, even when adjusted for health status and indicators of frailty. The reasons for this relationship are not clear, but some postulated mechanisms exist. It is possible that lower cholesterol levels can increase the risk of a variety of nonatherosclerotic diseases since cholesterol may play a direct role in immune response. Alternatively, preclinical diseases, chronic inflammation, or malnutrition may suppress cholesterol levels.",
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