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#129 Statins and the elderly: The Who, What and When?


CLINICAL QUESTION
QUESTION CLINIQUE
Which elderly patients should be offered what type of statin for cardiovascular disease (CVD) prevention?


BOTTOM LINE
RÉSULTAT FINAL
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
DONNÉES PROBANTES
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.   


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Author(s)
Auteur(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.