Tools for Practice


#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. 


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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).   
Primary Prevention: One systematic review of eight RCTs, 24,674 patients aged 65-82 years, ~3.5 years follow-up.2 Statistically significant reductions in: 
  • 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.   
Harms: Musculoskeletal adverse events,3 Number Needed to Harm=77 (average RCT 3.4 years). 
  • 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 
Context:  
  • 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.   
January 5, 2015

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Author(s):

  • G. Michael Allan MD CCFP
  • James L Silvius BA(Oxon) FRCPC

1. Afilalo J, Duque G, Steele R, et al. J Am Coll Cardiol. 2008; 51:37-45.

2. Savarese G, Gotto AM Jr, Paolillo S, et al. J Am Coll Cardiol. 2013; 62:2090-9.

3. Roberts CG, Guallar E, Rodriguez A. J Gerontol A Biol Sci Med Sci. 2007; 62:879-87.

4. Bonovas S, Sitaras NM. CMAJ. 2007; 176(5):649-54.

5. Shepherd J, Blauw GJ, Murphy MB, et al. Lancet. 2002; 360:1623-30.

6. Mihaylova B, Emberson J, Blackwell L, et al. Lancet. 2012; 380:581-90.

7. Dale KM, Coleman CI, Henyan NN, et al. JAMA. 2006; 295:74-80.

8. Stone NJ, Robinson JG, Lichtenstein AH, et al. Circulation. 2014; 129(25 Suppl 2):S1-S45.

9. Anderson TJ, Grégoire J, Hegele RA, et al. Can J Cardiol. 2013; 29:151-67.

10. Payne R. The University of Edinburgh Cardiovascular Risk Calculator. Online resource, last updated 28 May 2010. Available at http://cvrisk.mvm.ed.ac.uk/calculator/calc.asp. Accessed July 21, 2014.

Authors do not have any conflicts to disclose.