#129 Statins and the elderly: The Who, What and When?
CLINICAL QUESTION
Which elderly patients should be offered what type of statin for cardiovascular disease (CVD) prevention?
BOTTOM LINE
For primary prevention age 65-75, consider moderate-potency statins (example 10-20mg atorvastatin) for moderate or higher risk individuals (≥10% risk of CVD over 10 years based on Framingham score). No evidence to start statins in primary prevention patients >75. In secondary prevention age 65-82, there is evidence for moderate-potency (to high, as tolerated) statin. Pravastatin should likely not be first-line given the possible cancer signal for those >65.
Reading Tools for Practice Article can earn you MainPro+ Credits
Join NowAlready a CFPCLearn Member? Log in
EVIDENCE
Secondary Prevention: One systematic review of nine randomized controlled trials (RCTs), 19,569 patients aged 65-82 years, ~5 years follow-up.1 Statistically significant reductions in:
- All cause mortality: Relative Risk (RR) 0.78 (0.65-0.89).
- Estimated Number Needed to Treat (NNT)=28.
- Other outcomes: Coronary heart disease mortality (NNT=34), non-fatal myocardial infarction (NNT=38), stroke (NNT=58).
- Myocardial infarction: RR 0.61 (0.43-0.85), NNT 84.
- Stroke: RR 0.76 (0.62-0.93), NNT 143.
- No statistically significant reduction in death or CVD death.
- Cancer: Meta-regression4 of pravastatin trials suggests cancer incidence (multiple types5) increases in older patients:
- Risk Ratio: 0.92 at age 55, 1.06 at age 65, and 1.22 at age 75.
- May be spurious as older patient numbers low.
- Cancer incidence not increased with other statins.6,7
- Risk Ratio: 0.92 at age 55, 1.06 at age 65, and 1.22 at age 75.
- Meta-analyses of patients ≥65 are primarily from subgroups of RCTs and include few >75 (especially in primary prevention). Most used moderate-potency statin therapy (pravastatin 40mg or atorvastatin 10mg).1-3
- For patients >75, US guidelines8 advise:
- Offering statins to patients with CVD.
- Data does not clearly support use in those without CVD.
- Age is not an indication to stop statins in those tolerating it.
- Canadian guidelines9 advise clinical judgement guide therapy.
- Screening for lipid therapy should likely end at 75:
- Risk calculators10 generally do not include age >75 and there is no evidence for primary prevention >75.
Latest Tools for Practice
#364 Facing the Evidence in Acne, Part II: Oral Antibiotics
How effective are oral antibiotics in treating acne of at least mild-moderate severity?
#363 Making a difference in indifference? Medications for apathy in dementia
In patients with dementia, how safe and effective are stimulants, antidepressants, and antipsychotics for treating apathy?
#362 Facing the Evidence in Acne, Part I: Oral contraceptives and spironolactone in females
How effective are combined oral contraceptives (COC) and spironolactone for treating acne of at least mild-moderate severity in females?
