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Statins for Primary Prevention in Those Aged 70 Years and Older: A Critical Review of Recent Cholesterol Guidelines

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Abstract

The risk of atherosclerotic cardiovascular disease rises with age and remains the leading cause of death in older adults. Evidence for the use of statins for primary prevention in older adults is limited, despite the possibility that this population may derive significant clinical benefit given its increased cardiovascular risk. Until publication of the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the Management of Blood Cholesterol, and the 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease, guidelines for statin prescription in older adults remained unchanged despite new evidence of possible benefit in older adults. In this review, we present key updates in the 2018 and 2019 guidelines and the evidence informing these updates. We compare the discordant recommendations of the seven major North American and European guidelines on cholesterol management released in the past 5 years and highlight gaps in the literature regarding primary prevention of cardiovascular disease in older adults. As most cardiovascular events in older adults are nonfatal, we ask how clinicians should weigh the risks and benefits of continuing a statin for primary prevention in older adults. We also reframe the concept of deprescribing of statins in the older population, using the Geriatrics 5Ms framework: Mind, Mobility, Medications, Multi-complexity, and what Matters Most to older adults. A recent call from the National Institute on Aging for a statin trial focusing on older adults extends from similar concerns.

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Acknowledgements

The authors would like to thank Dr. Shoshana Streiter for her assistance with copy editing the manuscript.

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Authors and Affiliations

  1. New England Geriatric Research, Education, and Clinical Center (GRECC), VA Boston Healthcare System, Boston, MA, USA

    Chelsea E. Hawley & Ariela R. Orkaby

  2. Pharmacy Department, VA Boston Healthcare System, Boston, MA, USA

    Chelsea E. Hawley & John Roefaro

  3. Section of Geriatric Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA

    Daniel E. Forman

  4. Geriatric Research, Education, and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA

    Daniel E. Forman

  5. Division of Aging, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA

    Ariela R. Orkaby

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  1. Chelsea E. Hawley
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Corresponding author

Correspondence to Chelsea E. Hawley.

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Funding

Dr. Forman is supported by NIA Grants R01-AG060499-01, R01-AG051376, and P30-AG024827. Dr. Orkaby is supported by a Veterans Affairs Clinical Science Research and Development CDA-2 award (IK2-CX001800), a career development award from the Boston Claude D. Pepper Older Americans Independence Center, and NIA Grant P30-AG031679, and NIA GEMSSTAR award R03-AG060169. The funders played no role in the publication of the manuscript.

Conflict of interest

Chelsea E. Hawley, John Roefaro, Daniel E. Forman, and Ariela R. Orkaby have no conflicts of interest to declare that are directly relevant to the content of this article.

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Hawley, C.E., Roefaro, J., Forman, D.E. et al. Statins for Primary Prevention in Those Aged 70 Years and Older: A Critical Review of Recent Cholesterol Guidelines. Drugs Aging 36, 687–699 (2019). https://doi.org/10.1007/s40266-019-00673-w

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