Contrary to historical evidence, elevated LDL cholesterol levels increase the risk of heart attack and cardiovascular disease among the elderly, with older patients having more from statins and other cholesterol-lowering drugs than younger ones. Benefit from it. ..
“In contrast to previous historical studies, our data are important risk factors for myocardial infarction and atherosclerotic cardiovascular disease in the primary preventive cohort of individuals aged 70-100 years with LDL cholesterol. That’s what the university’s Doctor of Medicine, Borge Nordestgaard, said.Copenhagen, and the first Of the two studies published this week Lancet..
“Lowering LDL cholesterol in healthy people aged 70-100 is very likely to prevent cardiovascular disease from myocardial infarction and atherosclerosis, and is treated compared to people aged 20-69. The number required for is significantly reduced, “they add.
“These findings support the cumulative burden of LDL cholesterol over a lifetime and the notion that the risk of atherosclerotic cardiovascular disease, including myocardial infarction, increases with age,” Frederick J. Dr. Lahr and Falzanamohamed MBBCh add.Of the University of the Witwatersrand, South Africa editorial Published in both new studies The lancet.
They emphasize that these studies emphasize the need for clinicians to consider the ongoing risks associated with elevated LDL in the elderly.
They add that statins are also beneficial for young people who are at risk to prevent their condition from getting worse.
“The average age of patients in all the trials analyzed was over 60 years, which was the age at which cardiovascular disease of atherosclerosis was already well established,” the editor said.
“Lipid-lowering therapy should be started at a younger age, preferably before the age of 40, in people at risk of delaying the onset of atherosclerosis, rather than trying to manage a completely established or advanced condition. There is, “they emphasize.
No RCTs include patients over 70 years
Elevated LDL cholesterol levels are a known risk factor for myocardial infarction and atherosclerosis for people aged 40 to 75 years, and there is consensus on guidelines for treatment with statins.
However, the risks of people over the age of 70 are controversial. Some studies have shown that there is little or no association between elevated LDL cholesterol levels and an increased risk of myocardial infarction.
One factor in uncertainty is that few randomized controlled trials investigating questions include patients over the age of 70.
As a result, many clinical practice guidelines point to low levels of evidence in older patients, and some organizations have lower strength recommendations for treatment of older patients compared to younger patients.
Primary prevention: CV events increase with increasing LDL in the elderly
Nordegestaard et al. Investigated data from 91,131 baseline people in Copenhagen, Denmark, who did not have atherosclerosis or diabetes and were not taking statins.
Of the participants, 10,592 were 70 to 79 years old and 3188 were 80 to 100 years old.
Over an average follow-up of 7.7 years, 1515 participants developed their first myocardial infarction and 3389 developed atherosclerotic cardiovascular disease.
In the primary prophylaxis cohort, after multivariate adjustment, every 1.0 mmol / L increase in LDL cholesterol increased the risk of heart attack across the group (hazard ratio). [HR], 1.34). Increased risk is 80-100 years (HR, 1.28), 70-79 years (HR, 1.25), 60-69 years (HR, 1.29), 50-59 years (HR, 1.28), and 20-49 (20-49). HR, 1.68).
The risk of atherosclerotic cardiovascular disease was also increased with an increase of 1.0 mmol / L across LDL cholesterol (HR, 1.16) and all age groups (especially 70-100 years).
A greater increase in LDL cholesterol (≥5.0 mmol / L, indicating a possible familial hypercholesterolemia) is associated with a significantly higher risk of multivariate-adjusted heart attack in people aged 80-100 years. Was (HR, 2.99). The risk was also high among people between the ages of 70 and 79 (HR, 1.82).
The highest incidence was over 70 years old. The incidence was 8.5 heart attacks per 1000 people a year between 80 and 100 years and 5.2 heart attacks per 1000 people between 70 and 79 years. It was 2.5 per 1000 people between the ages of 60 and 70. 1.8 for 69, 50-59 years old, 0.8 for 20-49 years old.
“Absolute risk [of cardiovascular events] Of course, older people are much higher than those under 75, but what surprised me was how clear the results were on the relative risk scale, and the risks associated with elevated LDL were 80-100 years old. A young patient who was as expensive as a person, “said Nordestgaard of the University Hospital of Copenhagen, Denmark. Medscape Medical News..
Regarding the effects of cholesterol-lowering drugs, this study showed that 80 people between the ages of 80 and 100 needed to prevent a heart attack once every five years. The number of people between the ages of 50 and 59 was 439.
For more potent statins, the number required for treatment to prevent all types of cardiovascular disease events was reduced to 42 in patients aged 80-100 years when moderate intensity statins were used. Patients aged 70-79 are 88, 60-69 years, 345 are 50-59 years, and 769 are 20-49 years.
“The clinical significance of this is that older people actually appear to benefit from cholesterol-lowering therapy,” said Nordestgaard. “I think a lot of people have the idea that LDL isn’t important between the ages of 70 and 75, but it’s not.”
“These solid discoveries are novel,” he and his colleagues emphasize.
Despite these observations, South African editors said, “Whether lipid-lowering therapy should be started for primary prevention in people over the age of 75, because of the many risks and benefits that need to be balanced. Is unknown. “
Results of an ongoing randomized placebo-controlled trial (Starry) They may answer this question, they say. We are investigating primary prophylaxis in 18,000 elderly patients (aged 70+) who are randomly assigned to receive atorvastatin 40 mg / day or placebo. This study seeks to determine whether statin treatment prolongs the length of life without injury. It is assessed on the basis of survival other than permanent home care. Results are expected from 2022 to 2023.
Obvious reduction in elderly events, comparable to younger patients
In Second studyBarisgencer, MD, et al., Brigham and Women’s Hospital, Boston, Massachusetts, evaluated the effects of statins and other cholesterol-lowering drugs, including statins and ezetimibe and PCSK9 inhibitors, in older and younger patients.
Systematic review and meta-analysis of 29 randomized controlled trials Lancet, It was effectively presented as a poster as part of the American Heart Association’s (AHA) Annual Meeting. This included data on 244,090 patients, including 21,492 patients over the age of 75.
The meta-analysis included a study of cardiovascular outcomes of LDL cholesterol-lowering drugs recommended by the guidelines, with a median follow-up of at least 2 years and data on patients aged 75 years and older.
The results show that with a median follow-up of 2.2 to 6 years, statin use by older patients is associated with a 26% reduction in relative risk of major vascular events per 1 mmol / L reduction in LDL cholesterol. (P = .0019), which was comparable to a 15% risk reduction per 1 mmol / L reduction in LDL cholesterol in patients under 75 years of age (= .0019).P = Compared to older patients .37).
Treatment of older patients with LDL cholesterol-lowering drugs was also associated with a significant improvement in cardiovascular death outcomes (risk ratio). [RR], 0.85), myocardial infarction (RR, 0.80), stroke (RR 0.73), and coronary arterial blood circulation reconstruction (RR, 0.80).
“We found that both statin and non-statin LDL cholesterol-lowering treatments clearly reduced the risk of major vascular events, similar to those found in younger patients,” the authors write. I am.
“Cholesterol-lowering drugs are affordable drugs that reduce the risk of heart disease in millions of people around the world, but until now, the benefits to older people have been less certain,” Brigam said. Mark Sabateen, MD, MD, lead author of And Women’s Hospital, said. ,so Lancet Press release.
“According to our analysis, these treatments can reduce cardiovascular events and mortality in people over the age of 75 as effectively as young people. They cannot offset safety concerns. Taken together, these results were a cholesterol-lowering drug, including statin and non-statin therapies in the elderly. “
The editor agrees: “More than 80% of fatal cardiovascular events occur in patients age 65 and older, and the incidence of cardiovascular events is increasing in patients age 80 and older. Therefore, the results of a study by Gencer and colleagues are used. The effect of lipid-lowering therapy in elderly patients “
The authors of the two studies do not disclose the relevant financial relationship. Raal receives research grants, honors, or consulting fees from Amgen, Regeneron, Sanofi, Novartis, and Medicines Company for advisory board membership, expert opinion, and lectures on lipid-lowering drug therapy. I am.
The lancet. Released on November 10, 2020. First survey, Full text, Second study, Full text; editorial
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