New guidance issued on cholesterol management in older patients with no history of cardiovascular disease
The expert clinical consensus from the National Lipid Association and the American Geriatrics Society offered advice on risk assessment and initiating, monitoring, intensifying, and deprescribing statins, among other topics.
It may be reasonable to initiate statin therapy for primary prevention of atherosclerotic cardiovascular disease (ASCVD) events in patients older than age 75 years who have a low-density lipoprotein (LDL) cholesterol level of 70 to 189 mg/dL and no life-limiting illness, according to a recent expert clinical consensus.
The statement, developed by the National Lipid Association and the American Geriatrics Society, focuses on key questions related to treatment of hypercholesterolemia in individuals older than age 75 years without clinically manifest ASCVD. It was published April 10 by the Journal of the American Geriatrics Society.
For patients in this age group, traditional risk equations that calculate five- or 10-year risk are of uncertain utility, the statement said. Clinicians may consider using models adjusted for competing risks to calculate risk for ASCVD and the potential benefit of statins for primary prevention in specific individuals.
When there is clinical uncertainty about whether to start statins in patients ages 76 to 80 years who have an LDL cholesterol level of 70 to 189 mg/dL, it is reasonable to measure coronary artery calcium (CAC) and withhold statins if the score is 0. Shared decision making is reasonable in patients ages 76 to 80 years with an LDL cholesterol level of 70 to 189 mg/dL and a CAC score of 100 or higher or in the 75th percentile or higher versus age-, sex-, and race-matched patients, according to the statement.
The statement also included guidance on weighing safety concerns of statins; assessing the expected net benefit of statins; and initiating, monitoring, intensifying, and deprescribing statin therapy, as well as considering nonstatin therapies for ASCVD risk reduction.
The statement authors noted that results of trials currently in progress should shed more light on some of these questions and said that future trials should include more diverse participants.
“In addition, better risk stratification methods in older individuals using improved risk equations derived from diverse cohorts, new imaging modalities or new biomarkers may further enhance ASCVD prediction allowing better targeting of those at greatest risk,” they wrote. “While we await further evidence, in those who do not have a life limiting illness, primary prevention therapy with a statin can be considered as part of shared decision-making.”
An accompanying editorial noted several unique considerations in elderly patients without ASCVD, including frailty, comorbidities, and varying life expectancies. “Given the paucity of randomized controlled trials specifically in adults over 75 years without ASCVD, assessment of cardiovascular risk and treatment of hypercholesterolemia may not be straightforward for clinicians,” the editorialists wrote. “This consensus document emphasizes a patient-centered approach, weighing the benefits of lipid-lowering therapies against possible adverse effects and aligning treatment decisions with individual patient goals and values.”