Statin Prescribing in the Elderly: Special Considerations

  • M. LeyaEmail author
  • N. J. Stone
Statin Drugs (B. Wiggins, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Statin Drugs


Purpose of Review

Our aim was to examine the current evidence behind prescribing statins to individuals over 65 years of age with emphasis on those older than 75. Individuals over 75 years of age may often have multiple comorbidities and take many medications. Additionally, they are often underrepresented in randomized controlled trials (RCTs) of statins in older populations. While results of RCTs demonstrate the benefit of statin therapy in both primary and secondary prevention patients, clinicians must more carefully consider adverse effects and drug–drug interactions before prescribing statin therapy as well as determining the intensity in older individuals.

Recent Findings

Four primary prevention trials support statins for primary prevention following a clinician–patient risk discussion. Of these, JUPITER and HOPE-3 studied participants 70 years of age and over who derived benefit. However, in those over 85 years, available information is inadequate to guide decisions regarding statin therapy. Documented statin adverse effects include new onset diabetes, myopathy, and medication interactions. Although cognitive decline has been reported anecdotally, its incidence was comparable to placebo in two RCTs with validated cognitive evaluations. Concerns about significant liver and kidney injury with statins were not corroborated in RCTs. For most patients, the potential for reducing ASCVD risk outweighs possible adverse effects; however, in the elderly, the impact of drug treatment on cognition, musculoskeletal ability, and independence must be heavily weighed.


Given the limited high quality evidence for primary prevention in individuals over 75 years of age, neither the ACC–AHA nor USPSTF cholesterol guidelines recommend statin therapy for primary prevention in this patient population. If prescribed, physician judgment and shared decision-making are crucial. To aid clinicians, imaging studies of subclinical atherosclerosis may improve specificity of statin therapy to prevent ASCVD in the elderly in primary prevention.


Statin Elderly Treatment risk paradox Primary prevention Secondary prevention Adverse effects 


Compliance with Ethical Standards

Conflict of Interest

Marysa V. Leya and Neil J. Stone declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Wenger NK. Alice in lipidland. J Am Coll Cardiol. 2014;64(21):2193–5.CrossRefPubMedGoogle Scholar
  2. 2.
    William MA, Fleg JL, Ades PA, et al. Secondary prevention of coronary heart disease in the elderly (with emphasis on patients > or =75 years of age): an American Heart Association scientific statement from The Council on Clinical Cardiology Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention. Circulation. 2002;105(14):1735–43.CrossRefGoogle Scholar
  3. 3.
    Ko DT, Mamdani M, Alter DA. Lipid-lowering therapy with statins in high-risk elderly patients: the treatment-risk paradox. JAMA. 2004;291(15):1864–70.CrossRefPubMedGoogle Scholar
  4. 4.
    Gransbo K, Melander O, Wallentin L. Cardiovascular and cancer mortality in very elderly post-myocardial infarction patients receiving statin treatment. JACC. 2010;55(13):1363–9.CrossRefGoogle Scholar
  5. 5.
    Gaye B, Canonico M, Perier M, Samieri C, Berr C, Dartigues J, et al. Ideal cardiovascular health, mortality, and vascular events in elderly subjects. JACC. 2007;69(25):3015–26.CrossRefGoogle Scholar
  6. 6.
    •• Stone NJ, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. JACC. 2014;63(25 Pt B):2889–934. The latest guidelines from the ACC/AHA on statin prescribing, with special consideration of evidence-based practices doe prescribing in individuals over 65 years. Statins for secondary prevention are recommended for patients up to 85 years old, and for primary prevention with a risk discussion for patients 65 to 75 years old CrossRefPubMedGoogle Scholar
  7. 7.
    •• US Preventive Services Task Force. Statin use for the primary prevention of cardiovascular disease in adults. US Preventive Services Task Force recommendation statement. JAMA. 2016;316(19):1997–2007. The current recommendations from the USPSTF for prescribing statins in those 40 to 75 years of age based on their degree of cardiovascular risk recognizes the current limited evidence for prescribing statins for primary prevention in those older than 75 years of age CrossRefGoogle Scholar
  8. 8.
    Ali R, Alexander KP. Statins for the primary prevention of cardiovascular events in older adults: a review of the evidence. Am J Geri Pharmacotherapy. 2007;5(1):52–63.CrossRefGoogle Scholar
  9. 9.
    Corti MC, Guralnik JM, Salive ME, Harris T, Field TS, Wallace RB, et al. HDL cholesterol predicts coronary heart disease mortality in older persons. JAMA. 1995;274(7):539–44.CrossRefPubMedGoogle Scholar
  10. 10.
    Savarese G, Gotta AM, Paolillo S, et al. Benefits of statins in elderly subjects without established cardiovascular disease: a meta-analysis. JACC. 2013;62(22):2090–9.CrossRefPubMedGoogle Scholar
  11. 11.
    Robinson JG, Stone NJ. Identifying patients for aggressive cholesterol lowering: the risk curve concept. Am J Cardiol. 2006;98(10):1405–8.CrossRefPubMedGoogle Scholar
  12. 12.
    Collins R, Reith C, Emberson J, et al. Interpretation of the evidence for the efficacy and safety of statin therapy. Lancet. 2016;388:2532–61.CrossRefPubMedGoogle Scholar
  13. 13.
    Kuller L, Borhani N, Furberg C, Gardin J, Manolio T, O’Leary D, et al. Prevalence of subclinical atherosclerosis and cardiovascular disease and association with risk factors in the Cardiovascular Health Study. Am J Epidemiol. 1994;139(12):1164–79.CrossRefPubMedGoogle Scholar
  14. 14.
    Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, et al. Heart disease and stroke statistics-2015 update: a report from the American Heart Association. Circulation. 2015;131:e29–e322.CrossRefPubMedGoogle Scholar
  15. 15.
    Flack JM, Ferdinand KC, Nasser SA. Epidemiology of hypertension and cardiovascular disease in African Americans. J Clin Hyperten. 2003;5(1):5–11.CrossRefGoogle Scholar
  16. 16.
    Han BH, Sutin D, Williamston JD, et al. Effect of statin treatment vs usual care in primary cardiovascular prevention among older adults: the ALLHAT-LLT randomized clinical trial. JAMA. 2017;177(7):955–65.Google Scholar
  17. 17.
    Ridker PM, Lonn E, Paynter NP, Glynn R, Yusuf S. Primary prevention with statin therapy in the elderly: new meta-analyses from the contemporary JUPITER and HOPE-3 randomized trials. Circulation. 2017;135(20):1979–81.CrossRefPubMedGoogle Scholar
  18. 18.
    Shepherd J, Blauw GJ, Murphy MB, et al. Pravastatin in elderly individuals at risk of vascular disease (PROSPER): a randomised controlled trial. Lancet. 2002;360:1623–30.CrossRefPubMedGoogle Scholar
  19. 19.
    Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Scandinavian Simvastatin Survival Study Group. Lancet. 1994;344:1383–9.Google Scholar
  20. 20.
    Sacks FM, Pfeffer MA, Moye LA, et al. The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. Cholesterol and Recurrent Events trial investigators. NEJM. 1996;335:1001–9.CrossRefPubMedGoogle Scholar
  21. 21.
    Prevention of cardiovascular events and death with pravastatin in patients with coronary heart disease and a broad range of initial cholesterol levels. The Long-Term Intervention with Pravastatin in Ischemic Disease (LIPID) study group. N Engl J Med. 1998;339:1349–57.CrossRefGoogle Scholar
  22. 22.
    Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomized placebo-controlled trial. Lancet. 2002;360:7–22.CrossRefGoogle Scholar
  23. 23.
    Afilalo J, Duque G, Steele R, et al. Statins for secondary prevention in elderly patients: a hierarchical Bayesian meta-analysis. JACC. 2008;51(1):37–45.CrossRefPubMedGoogle Scholar
  24. 24.
    • Katz DH, Intwala SS, Stone NJ. Addressing statin adverse effects in the clinic. J Cardiovasc Pharmacol Ther. 2014;19(6):533–42. Provides a framework for addressing the most relevant adverse effects of statins in the clinic setting CrossRefPubMedGoogle Scholar
  25. 25.
    Ridker PM, et al. Rosuvastatin to prevent vascular events in men and women with elevated C-reactive protein. N Engl J Med. 2008;359(21):2195–207.CrossRefPubMedGoogle Scholar
  26. 26.
    LaRosa JC, Grundy SM, Waters DD, Shear C, Barter P, Fruchart J, et al. Intensive lipid lowering with atorvastatin in patients with stable coronary disease. New Engl J Med. 2005;352:1425–35.CrossRefPubMedGoogle Scholar
  27. 27.
    Cholesterol Treatment Trialists’ (CTT) Collaboration. Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of data from 170000 participants in 26 randomized trials. Lancet. 2010;376:1670–81.CrossRefGoogle Scholar
  28. 28.
    Taylor BA, Lorson L, White CM, Thompson PD. A randomized trial of coenzyme Q10 in patients with confirmed statin myopathy. Atherosclerosis. 2015;238(2):329–35.CrossRefPubMedGoogle Scholar
  29. 29.
    Nissen SE, Stroes E, Dent-Acosta RE, Rosenson RS, Lehman SJ, Sattar N, et al. Efficacy and tolerability of evolocumab vs ezetimibe in patients with muscle-related statin intolerance: the GAUSS-3 Randomized Clinical Trial. JAMA 2016;315(15):1580–1590.Google Scholar
  30. 30.
    Joy TR, Monjed A, Zou GY, Hegele RA, McDonald CG, Mahon JL. N-of-1 (single-patient) trials for statin-related myalgia. Ann Intern Med. 2014;160(5):301–10.CrossRefPubMedGoogle Scholar
  31. 31.
    Davis SA, Feldman SR, Taylor SL. Use of St. John’s Wort in potentially dangerous combinations. J Altern Complement Med. 2014;20(7):578–9.CrossRefPubMedGoogle Scholar
  32. 32.
    Russo MW, Hoofnagle JH, Gu J, Fontana RJ, Barnhart H, Kleiner DE, et al. Spectrum of statin hepatotoxicity: experience of the drug-induced liver injury network. Hepatology. 2014;60:679–86.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Fuster V, Muntendam P, Mehran R, Baber U, Sartori S, Falk E. A simple disease-guided approach to personalize ACC/AHA-recommended statin allocation in elderly people: the BioImage Study. J Am Coll Cardiol. 2016;68(9):881–91.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2017

Authors and Affiliations

  1. 1.Department of Medicine, Feinberg School of MedicineNorthwestern UniversityChicagoUSA
  2. 2.Division of Cardiology; Department of Medicine, Feinberg School of MedicineNorthwestern UniversityChicagoUSA

Personalised recommendations