Elderly patients at high risk for acute cardiovascular events benefit as much from LDL cholesterol reduction as do younger patients but are significantly less likely to be prescribed statins, according to study findings presented at the annual meeting of the Society of General Internal Medicine. Just as in younger patients, the magnitude of cardiovascular benefit is proportional to the magnitude of LDL reduction said by the Massachusetts Veterans Epidemiology Research and Information Center at Boston University and the Boston Veterans Affairs (VA) Healthcare System.
The evidence supports treating older patients with the same high doses of statins we use in younger patients. Although it’s well known that a graded relationship between magnitude of LDL reduction and magnitude of cardiovascular benefit exists in general in the cardiovascular population, there has been debate as to whether aggressive LDL cholesterol reduction is similarly beneficial in elderly patients. They studied 23,513 veterans from the New England VA Healthcare database who were diagnosed with coronary artery disease, peripheral vascular disease, or diabetes mellitus.
Eligible subjects were followed retrospectively for a combined outcome of first acute myocardial infarction or revascularization. In the study, significantly fewer elderly patients (older than 75.3 years) were prescribed statins, compared with younger patients (70% vs. 78%-82%; P less than .0001), reported. They said that despite this, there were enough subjects in the oldest age quartile who achieved a large LDL reduction to demonstrate that such patients experienced fewer events than did their counterparts, who had achieved only small or medium LDL reductions.
Pre-outcome LDL reduction was categorized as no reduction (less than 10mg/dL), small reduction (10-40mg/dL), moderate reduction (40-70mg/dL), and large reduction (more than 70mg/dL) of Brigham and Women’s Hospital, Boston. For each age quartile, a significant relationship was observed at any final LDL cholesterol level between the amount of LDL change that was achieved and the magnitude of the risk reduction for the combined outcome of first acute myocardial infarction and surgical or percutaneous revascularization.
In patients who achieved large LDL reductions, compared with those with no reduction, the hazard ratios for the primary outcomes were similar across age quartiles after adjustment for age, gender, cholesterol-modifying therapy, hypertension, renal disease, thyroid disease, and cerebrovascular disease. In the subgroup of 2,038 patients aged 80 or older, the hazard ratio for those who achieved only a small reduction in LDL cholesterol was 0.65, dropping to 0.27 for those with the largest LDL reduction, reported.
Median baseline age in the cohort was 67.1 years, and average follow-up time was 3.86 years. In all, 6,150 patients had a myocardial infarction or underwent revascularization during the study. In her presentation, doctor conceded that the study might have missed some outcome events that occurred outside of the VA medical system. She also noted that the investigators did not have data on race, smoking, or socio-economic status and, thus, were unable to control for those variables.
The findings, however, are similar to those seen in previous mega-analyses and in the recently published Study Assessing Goals in the Elderly (SAGE), in which a 67% reduction in risk for all-cause death was seen in subjects treated with a daily 80mg dose of atorvastatin.