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Is it Advantageous to Lower Cholesterol in the Elderly Hypertensive?

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Abstract

Hypertension is often associated with other risk factors for cardiovascular disease, including elevated levels of cholesterol, and casual systolic hypertension is a very prevalent finding in the elderly (50% of women over the age of 80 have casual systolic blood pressures ≥ 160 mmHg). Total cholesterol levels steadily increase with age from 20 to 65, following which they decrease slightly in men and tend to plateau in women. Elevated cholesterol levels are not uncommon in the elderly (61% of women aged between 65 and 74 have total cholesterol levels over 6.2 mmol/L [240 mg/dL]). From the data available, it is reasonable to conclude that after the age of 65, increased blood lipids, although still a risk factor for coronary heart disease (CHD), become less pronounced as risk factors and that by 75 years of age their predictive value has disappeared. Indeed, in the very elderly, there is evidence to suggest that high total cholesterol is associated with longevity. In elderly hypertensives with elevated serum cholesterol, differing risks have been reported. The European Working Party on Hypertension in the Elderly (EWPHE) trial suggested a negative relationship between cholesterol and mortality, while the Systolic Hypertension in the Elderly Program (SHEP) trial suggested a positive relationship.

With regards to intervention, it is well documented that antihypertensive treatment in elderly hypertensives up to the age of 80 who have blood pressures over 160 mmHg systolic is associated with significant reductions in stroke and cardiovascular events. The efficacy of dietary modification in reducing cholesterol in the elderly has been supported by some studies but not by all. Three major intervention trails using statins have shown that in elderly patients up to the age of 70–75 who have established CHD, lipid-lowering therapy can be of benefit. The experience from these and other trials suggests that statins are generally well tolerated in the elderly. It is difficult and premature to extrapolate these results to elderly patients who have hypertension and raised cholesterol levels without established CHD. Further trials are required before routinely suggesting it is advantageous to lower cholesterol in an elderly hypertensive who does not have pre-existing evidence of CHD. It is possible that large numbers may prove to require treatment.

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References

  1. Medical Research Council Working Party. MRC trial of treatment of hypertension in older adults: principal results. Br Med J 1992;304:405-412.

    Google Scholar 

  2. Coope JN, Warrender TS. Randomised trial of hypertension in elderly patients in primary care. Br Med J 1986;293:1145-1151.

    Google Scholar 

  3. Amery A, Birkenhager WH, Brixko P, et al. Mortality and morbidity results from the European Working Party on High Blood Pressure in the Elderly trial. Lancet 1985;i:1349-1354.

    Google Scholar 

  4. Dahlöf B, Lindholm LH, Hanson L, et al. Morbidity and mortality in the Swedish trial in old patients with hypertension (STOP-Hypertension). Lancet 1991;338:1281-1285.

    Google Scholar 

  5. SHEP Co-operative Research Group. Prevention of stroke by anti-hypertensive drug treatment in older persons with isolated systolic hypertension. JAMA 1991;265:3255-3264.

    Google Scholar 

  6. Staessen JA, Fagard R, Thijs L, et al. Randomised double-blind comparison of placebo and active treatment for older patients with systolic hypertension. Lancet 1997;350:757-764.

    Google Scholar 

  7. Miettinen TA, Pyörälä K, Olsson AG, et al. Cholesterol-lowering therapy in women and elderly patients with myocardial infarction or angina pectoris. Findings from the Scandinavian Simvastatin Survival Study. Circulation 1997;96:4211-4218.

    Google Scholar 

  8. Lewis SJ, Moye LA, Sacks FM, et al. Effect of pravastatin on cardiovascular events in older patients with myocardial infarction and cholesterol levels in the average range. Results of the Cholesterol and Recurrent Events (CARE) trial. Ann Intern Med 1998;129:681-689.

    Google Scholar 

  9. Manolio TA, Ettinger WH, Russell P, et al. Epidemiology of cholesterol levels in older adults. The Cardiovascular Health Study. Circulation 1993;87:728-737.

    Google Scholar 

  10. Ettinger WH, Wahl PW, Kuller LH, et al. Lipoprotein lipids in older people: results from the Cardiovascular Health Study. Circulation 1992;86:858-869.

    Google Scholar 

  11. Johnson CL, Rifkind BM, Sempos CT, et al. Declining serum cholesterol levels among US adults. The National Health and Nutrition Examination Surveys. JAMA 1993;269:3002-3008.

    Google Scholar 

  12. Kannel WB, Garrison RJ, Wilson PWF. Obesity and nutrition in elderly diabetic patients. Am J Med 1986;80(Suppl 5A):22.

    Google Scholar 

  13. Kannel WB. Range of serum cholesterol values in the population developing coronary heart disease. Am J Cardiol 1995;76:69C-77C.

    Google Scholar 

  14. Sempos CT, Cleeman JI, Carroll MD, et al. Prevalence of high blood cholesterol among US adults. JAMA 1993;269:3009-3014.

    Google Scholar 

  15. Manolio TA, Furberg CD, Wahl PW, et al. Eligibility for cholesterol referral in community-dwelling older adults. Ann Intern Med 1992;116:641-649.

    Google Scholar 

  16. Anderson KM, Castelli WP, Levy D. Cholesterol and mortality: 30 years of follow up from the Framingham study. JAMA 1987;257:2176-2180.

    Google Scholar 

  17. Kronmal RA, Cain KC, ZhanY, et al. Total serum cholesterol levels and mortality risk as a function of age: a report based on the Framingham data. Arch Intern Med 1993;153:1065-1073.

    Google Scholar 

  18. Gartside PS, Glueck CJ. The important role of modifiable dietary and behavioral characteristics in the causation and prevention of coronary heart disease hospitalization and mortality: the prospective NHANES I follow-up study. J Am Coll Nutr 1995;14:71-79.

    Google Scholar 

  19. Krumholz HM, Seeman RE, Merrill SS, et al. Lack of association between cholesterol and coronary heart disease mortality and morbidity and all-cause mortality in persons older than 70 years. JAMA 1994;272:1335-1340.

    Google Scholar 

  20. Roussouw JE, Mangdiwala S, Gordon DJ, et al. Plasma lipids as predictors of CHD in older men and women: the LRC follow-up study. Circulation 1990;82(Suppl 3):346.

    Google Scholar 

  21. Shipley MJ, Pocock SJ, Marmot MG. Does plasma cholesterol concentration predict mortality from coronary heart disease in elderly people? 18 year follow-up in the Whitehall study. Br Med J 1991;303:89-92.

    Google Scholar 

  22. Castelli WP, Wilson PWF, Levy D, et al. Cardiovascular risk factors in the elderly. Am J Cardiol 1989;63:12H-19H.

    Google Scholar 

  23. Corti MC, Guralnik JM, Salive E, et al. Clarifying the direct relationship between total cholesterol levels and death from coronary heart disease in older persons. Ann Intern Med 1997;126:753-760.

    Google Scholar 

  24. Corti MC, Guralnik JM, Salive E, et al. HDL cholesterol predicts coronary heart disease mortality in older persons. JAMA 1995;274:1335-1340.

    Google Scholar 

  25. Weijenberg MP, Feskens EJM, Bowles CH, et al. Serum total cholesterol and systolic blood pressure as risk factors for mortality from ischemic heart disease among elderly men and women. J Clin Epidemiol 1994;47:197-205.

    Google Scholar 

  26. Manolio TA, Pearson TA, Wenger NK, et al. Cholesterol and heart disease in older persons and women. Review of an NHLBI workshop. Ann Epidemiol 1992;2:161-176.

    Google Scholar 

  27. Weverling-Rijnsburger AWE, Blauw GJ, Lagaay AM, et al. Total cholesterol and risk of mortality in the oldest old. Lancet 1997;350:1119-1123.

    Google Scholar 

  28. Iso H, Jacobs D Jr, Wentworth D, et al. Serum cholesterol and six-year mortality from stroke in 350,977 men screened for the Multiple Risk Factor Intervention trial. N Eng J Med 1989;320:904-910.

    Google Scholar 

  29. Tell G, Crouse J, Furberg C. Relation between blood lipids, lipoproteins, and cerebrovascular atherosclerosis: a review. Stroke 1988;19:423-430.

    Google Scholar 

  30. Gordon T, Kannel W, Castelli W, et al. Lipoproteins, cardiovascular disease and death: the Framingham study. Arch Intern Med 1981;141:1128.

    Google Scholar 

  31. Atkins D, Psaty B, Koepsell T, et al. Cholesterol reduction and the risk of stroke in men: a meta-analysis of randomised controlled trials. Ann Intern Med 1993;119:136-145.

    Google Scholar 

  32. Prospective Studies Collaboration. Cholesterol, diastolic blood pressure, and stroke: 13000 strokes in 450000 people in 45 prospective cohorts. Lancet 1995;346:1647-1653.

    Google Scholar 

  33. Kagan A, Popper J, Rhoads G. Factors related to stroke incidence in Hawaiian Japanese men: the Honolulu Heart Study. Stroke 1980;11:14-21.

    Google Scholar 

  34. Iribarred C, Jacobs DR, Sadler M, et al. Low total serum cholesterol and intracerebral haemorrhagic stroke: Is the association confined to elderly men? The Kaiser Permanente Medical Care Program. Stroke 1996;27:1993-1998.

    Google Scholar 

  35. Lindenstrom E, Boysen G, Nyboe J. Influence of total cholesterol, high density lipoprotein cholesterol, and triglycerides on risk of cerebrovascular disease: the Copenhagen City Heart study. Br Med J 1994;309:11-15.

    Google Scholar 

  36. Simmons LA, McCallum J, Friedlander Y, et al. Risk factors for ischaemic stroke. Dubbo Study of the Elderly. Stroke 1998;29:1341-1346.

    Google Scholar 

  37. Reaven GM, Lithell H, Lansberg L. Hypertension and associated metabolic abnormalities-the role of insulin resistance and the sympatho-adrenal system. N Eng J Med 1996;334:374-381.

    Google Scholar 

  38. Kannel WB. Hypertension as a risk factor for cardiac events-epidemiologic results of long-term studies. J Cardiovasc Pharmacol 1993;21(Suppl 2):S27-S37.

    Google Scholar 

  39. Staessen J, Amery A, Birkenhäger W, et al. Is high serum cholesterol associated with a longer survival in elderly hypertensives? J Hypertens 1990;8:755-761.

    Google Scholar 

  40. Frost PH, Davis BR, Burlando AJ, et al. Serum lipids and incidence of coronary heart disease. Findings from the Systolic Hypertension in the Elderly Program (SHEP). Circulation 1996;94:2381-2388.

    Google Scholar 

  41. Neaton JD, Blackburn H, Jacobs D, Kuller L, et al. Serum cholesterol level and mortality findings for men screened for the multiple risk factor intervention trial. Multiple Risk Factor Intervention Trial research group. Arch Intern Med 1992;152:1490-1500.

    Google Scholar 

  42. World Health Organisation European Collaborative Group. European collaborative trial of multifactorial prevention of coronary heart disease. Lancet 1986;i:869-872.

    Google Scholar 

  43. Frantz ID, Dawson EA, Ashman PL, et al. Test of effect of lipid lowering by diet on cardiovascular risk. The Minnesota Coronary Survey. Atherosclerosis 1989;9:129-135.

    Google Scholar 

  44. Strandberg TE, Salomaa VV, Naukkarinen VA, et al. Long term mortality after 5 year multifactorial primary prevention of cardiovascular diseases in middle age. JAMA 1991;266:1225-1229.

    Google Scholar 

  45. Dayton S, Pearce ML, Hashimoto S, et al. A controlled trial of a diet high in unsaturated fat preventing complications in atherosclerosis. Circulation 1969;39/40(Suppl II):63.

    Google Scholar 

  46. Leren P. The Oslo Heart Study: eleven year report. Circulation 1970;XLII:935-942.

    Google Scholar 

  47. Woodhill JM, Palmer AJ, Leelarthaepin C, et al. Low fat, low cholesterol diet in secondary prevention of coronary heart disease. Adv Exp Med Biol 1978;109:317-330.

    Google Scholar 

  48. Burr ML, Fehily AM, Gilbert JF, et al. Effects of changes in fat, fish and fibre intakes on death and myocardial reinfarction: diet and reinfarction trial (DART). Lancet 1989;ii:757-761.

    Google Scholar 

  49. Schaefer EJ, Lichenstein AH, Lamon-Fava S. Efficacy of a National Cholesterol Education Program Step 2 diet in normolipidemic and hypercholesterolemic middle aged and elderly men and women. Arterioscler Thromb Vasc Biol 1995;15:1079-1085.

    Google Scholar 

  50. Lowik MR, Wedel M, Kok FJ, et al. Nutrition and serum cholesterol levels among elderly men and women. J Gerontol 1991;46:M23-M28.

    Google Scholar 

  51. LaRosa JC, Applegate W, Crouse III JR, et al. Cholesterol lowering in the elderly. Results of the Cholesterol Reduction in Seniors Program (CRISP) pilot study. Arch Intern Med 1994;154:529-539.

    Google Scholar 

  52. Hunningshake DB, Stein EA, Dujovne CA, et al. The efficacy of intensive dietary therapy alone or combined with lovastatin in outpatients with hypercholesterolemia. N Eng J Med 1993;328:1213-1219.

    Google Scholar 

  53. Ives DG, Kuller LH, Traven ND. Use and outcome of a cholesterol-lowering intervention for rural elderly subjects. Am J Prev Med 1993;9:274-281.

    Google Scholar 

  54. Knapp HR, Fitzgerald GA. The antihypertensive effects of fish oil. A controlled study of polyunsaturated fatty acid supplements in essential hypertension. N Eng J Med 1989;320:1610-1611.

    Google Scholar 

  55. Margolin G, Huster G, Glueck CJ, et al. Blood pressure lowering in elderly subjects: a double-blind crossover study of omega-3 and omega-6 fatty acids. Am J Clin Nutr 1991;53:562-572.

    Google Scholar 

  56. Schaefer EJ, Lichenstein AH, Lamon-Fava S, et al. Effects of National Cholesterol Education Program Step 2 diets relatively high or relatively low in fish-derived fatty acids on plasma lipoproteins in middle-aged and elderly subjects. Am J Clin Nutr 1996;63:234-241.

    Google Scholar 

  57. Mori TA, Bao DQ, Burke V, et al. Purified docosahexaenoic acid but not eicosapentaenoic acid lowers ambulatory blood pressure and heart rate inhumans-arandomised controlled trial. J Hypertens 1999;17(Suppl 3):S3.

    Google Scholar 

  58. The Long-term Intervention with Pravastatin in Ischaemic Disease (LIPID) Study Group. Prevention of cardiovascular events and death with pravastatin inpatients with coronary heart disease and a broad range of initial cholesterol levels. N Eng J Med 1998;339:1349-1357.

    Google Scholar 

  59. The Scandinavian Simvastatin Study Group. Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Study (4S). Lancet 1994;344:1383-1389.

    Google Scholar 

  60. 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. N Eng J Med 1996;335:1001-1009.

    Google Scholar 

  61. Plehn JF, Davis BR, Scaks FM, et al. Reduction of stroke incidence after myocardial infarction with pravastatin. The Cholesterol and Recurrent Events (CARE) Study. Circulation 1999;99:216-223.

    Google Scholar 

  62. Tonolo G, Melis MG, Formato M, et al. The efficacy of simvastatin in reducing cardiovascular risk factors in hypertensive type 2 diabetic patients cannot be explained solely by its effects on LDL-cholesterol. J Hypertens 1999;17(Suppl 3).

  63. Rowland Yeo K, Yeo WW, Wallis EJ, et al. Does diltiazem enhance cholesterol reduction by simvastatin. J Hypertens 1999;17(Suppl 3):S59.

    Google Scholar 

  64. Sposito AC, Mansur AP, Coelho OR, et al. Additional reduction in blood pressure after cholesterol-lowering treatment by statins (lovastatin or pravastatin) in hypercholesterolemic patients using angiotensin-converting enzyme inhibitors (enalapril or lisinopril). Am J Cardiol 1999;83:1497-1499.

    Google Scholar 

  65. Lye M, Valacio R, Reckless PD, et al. Elderly patients with hypercholesterolaemia: a double-blind study of the efficacy, safety and tolerability of fluvastatin. Coronary Artery Dis 1998;9:583-590.

    Google Scholar 

  66. Morgan RE, Palinkas LA, Barrett-Connor El, et al. Serum cholesterol and depressive symptoms in older men. Lancet 1993;341:75-79.

    Google Scholar 

  67. Dealberto MJ, Ducimetiere P, Mainard F, et al. Serum lipids and depression. Lancet 1993;341:435.

    Google Scholar 

  68. Lindberg G, Rastam L, Gullberg B, et al. Low serum cholesterol concentration and short term mortality from injuries in men and women. Br Med J 1992;305:309-314.

    Google Scholar 

  69. Engelberg H. Low serum cholesterol and suicide. Lancet 1992;339:727-729.

    Google Scholar 

  70. Wardle J, Armitage J, Collins K. Randomised placebo controlled trial of effect on mood of lowering cholesterol concentration. Br Med J 1996;313:75-78.

    Google Scholar 

  71. Santello NC, Barber BL, Applegate WB, et al. Effect of pharmacologic lipid lowering on health-related quality of life in older persons: results from the Cholesterol Reduction in Seniors Program (CRISP) pilot. J Am Geriatr Soc 1997;45:8-14.

    Google Scholar 

  72. Zavaroni I, Bonora E, Pagliara M, et al. Risk factors for coronary heart disease in patients with hyperinsulinemia and normal glucose tolerance. N Eng J Med 1989;320: 702-706.

    Google Scholar 

  73. Verdery RB, Goldberg AP. Hypocholesterolemia as a predictor of death: a prospective study of 224 nursing home residents. J Geronto 1991;46:M84-M90.

    Google Scholar 

  74. Davis RR, Cutler JA, Gordon DJ, et al. Rationale and design for the Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). ALLHAT research group. Am J Hypertens 1996;4:342-360.

    Google Scholar 

  75. Dahlöf B, Sever PS, Poulter NR, et al. The Anglo-Scandinavian cardiac outcomes trial (ASCOT). J Hypertens 1998;16(Suppl 2)S212.

    Google Scholar 

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  1. Section of Elderly Care, Hammersmith Hospital, London, UK

    Nigel Beckett

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  1. Nigel Beckett
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Beckett, N., Nunes, M. & Bulpitt, C. Is it Advantageous to Lower Cholesterol in the Elderly Hypertensive?. Cardiovasc Drugs Ther 14, 397–405 (2000). https://doi.org/10.1023/A:1007812232328

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