No randomized controlled trials exist that identify and treat hyperlipidemia for advanced elderly patients (age >80 years). Expert and consensus guidelines state that hyperlipidemia found in any patient with coronary artery disease (CAD), or at risk of CAD, should be treated irrespective of age; however, evidence is limited to support lowering lipids for advanced elderly patients with and without known CAD (strength of recommendation: C, based on expert and consensus guidelines)

Britigan, Denise H.

Rogers, John C., 1949-

Shah, Krupa

University of Missouri: MOspace

356 VOL 55, NO 4 / APRIL 2006  THE JOURNAL OF FAMILY PRACTICECLINICAL INQUIRIESHence, it is unclear whether the benefit ofstatins on cardiovascular mortality extendsto advanced elderly patients. These peoplecomprise the fastest-growing segment ofthe population, increasing by about 3%per year. They tend to experience concomi-tant chronic illness, shorter life expectancy,and physical frailty, leading to quality-of-life and end-of-life issues. Is it beneficialand cost-effective to treat these very elder-ly patients for hyperlipidemia?The first prospective, randomizedtrial8 of the use of statins among the elder-ly examined the impact of pravastatin ther-apy on primary and secondary preventionof cardiovascular and cerebrovascularevents for men and women (age 70–82years), with a history of vascular disease orwith risk factors for vascular disease. The■ Evidence summaryCAD is the leading cause of death in theUnited States and is a significant cause ofmortality and morbidity for those aged 65years and older. Multiple studies havedemonstrated the value of lipid-loweringtherapy for the primary and secondaryprevention of CAD. Most of these studieshave not been specifically oriented towardthe elderly; however, substantial data fromsubgroup analyses of older subjects frommajor lipid treatment trials has consistent-ly demonstrated the beneficial effects ofstatin therapy in reducing all cardiovascu-lar events for patients with known CADwho are 65 and older.2–7Unfortunately, randomized trials ofhyperlipidemia treatment with statins haveenrolled few people aged 80 and above.Should we identify and treat hyperlipidemia in the advanced elderly?No randomized controlled trials exist that identifyand treat hyperlipidemia for advanced elderlypatients (age >80 years). Expert and consensusguidelines state that hyperlipidemia found in anypatient with coronary artery disease (CAD), or atrisk of CAD, should be treated irrespective of age;however, evidence is limited to support loweringlipids for advanced elderly patients with and with-out known CAD (strength of recommendation: C,based on expert and consensus guidelines).1E V I D E N C E - B A S E D A N S W E RWhen prescribing lipid-lowering therapy for olderadults, assess competing risks as a function of age Many of my patients are over age 82, and theseare precisely the ones for whom additional data on the benefits of lipid-lowering would be helpful.Unfortunately, there are no data on lipid-loweringtherapy in this population. Polypharmacy is a concern when caring for elderly patients, as arethe practical difficulties of medication expense andtaking drugs properly. Additionally, because olderpatients have many competing risks for death, the absolute effect of treating any one problem isrelatively small. When prescribing lipid-loweringtherapy for older adults, as is often the case withgeriatrics, one must assess the “competing risks”as a function of age and, for now, base the treatment decision on these risks rather than evidence-based medicine for the evidence is not yet available.Cari Levy, MD, CMDDivision of Health Care Policy and Research, University of Colorado, AuroraKrupa Shah, MD, MPH, John Rogers, MD, MPH, MEdDepartment of Family and Community Medicine, Baylor College of Medicine, HoustonDenise Britigan, MAAcademic Information Technology and Libraries, University of Cincinnati C L I N I C A L C O M M E N T A R YJFP_0406_CI.Final  3/16/06  2:56 PM  Page 356Copyrigh® Dowden Health Media  For personal use onyFor mass reproduction, content licensing and permissions contact Dowden Health Media.VOL 55, NO 4 / APRIL 2006 357w w w. j f p o n l i n e . c o msample of 5804 participants was random-ized to receive pravastatin 40 mg or place-bo, followed for an average of 3.2 years,and monitored for the combined endpointof myocardial infarction (MI), stroke, andCAD death. The study showed 19% (95%confidence interval [CI], 6–31; P=.006)proportional reduction in the rate of coro-nary death or nonfatal MI. The absoluterisk reduction for coronary death or non-fatal myocardial infarction or nonfatalstroke was significant (2.2%, numberneeded to treat [NNT]=45). Rates ofadverse drug events were similar in theintervention and control groups.8Serum cholesterol normally declineswith age; so the benefit of lowering lipidswith medication in this age group is unclear.Furthermore, a meta-analysis9 showed aninverse relationship between total serumcholesterol and all-cause mortality for peo-ple aged 80 and above, raising the possibil-ity that lowering cholesterol may be detri-mental in this age group. Two other cohortstudies10,11 found that low cholesterol wasrelated to all-cause mortality, even whenadjusted for health status and indicators offrailty. The reasons for this relationship arenot clear, but some postulated mechanismsexist. It is possible that lower cholesterollevels can increase the risk of a variety ofnonatherosclerotic diseases since cholesterolmay play a direct role in immune response.Alternatively, preclinical diseases, chronicinflammation, or malnutrition may sup-press cholesterol levels.4Recommendations from othersNational Cholesterol Education ProgramAdult Treatment Panel III guidelines1 out-line risk identification and management ofhyperlipidemia in all age groups with noexceptions noted for the very elderly. Arecent scientific statement from theAmerican Heart Association12 outlined thedata on the implementation of all primaryand secondary prevention guidelines forthe elderly and emphasized that the latestcholesterol treatment recommendationsshould be applied to all eligible adults,with no exceptions for the very elderly.R E F E R E N C E S1. Executive Summary of the Third Report of theNational Cholesterol Education Program (NCEP)Expert Panel on Detection, Evaluation, and Treatmentof High Blood Cholesterol in Adults (Adult TreatmentPanel III). JAMA 2001; 285:2486–2497.2. Heart Protection Study Collaborative Group. MRC/BHFHeart Protection Study of cholesterol lowering withsimvastatin in 20,536 high-risk individuals: A ran-domised placebo-controlled trial. Lancet 2002;360(9326):7–22.3. Randomised trial of cholesterol lowering in 4444patients with coronary heart disease: TheScandinavian Simvastatin Survival Study (4S). Lancet1994; 344:1383–1389.4. Miettinen TA, Pyorala K, Olsson AG, et al. Cholesterol-lowering therapy in women and elderly patients withmyocardial infarction or angina pectoris: Findingsfrom the Scandinavian Simvastatin Survival Study(4S). Circulation 1997; 96:4211–4218. 5. Pfeffer MA, Sacks FM, Moye LA, et al. Cholesterol andRecurrent Events: A secondary prevention trial for nor-molipidemic patients. CARE Investigators. Am JCardiol 1995; 76:98C–106C. 6. Lewis SJ, Moye LA, Sacks FM, et al. Effect of pravas-tatin on cardiovascular events in older patients withmyocardial infarction and cholesterol levels in theaverage range. Results of the Cholesterol andRecurrent Events (CARE) trial. Ann Intern Med 1998;129:681–689. 7. Hunt D, Young P, Simes J, et al. Benefits of pravastatinon cardiovascular events and mortality in olderpatients with coronary heart disease are equal to orexceed those seen in younger patients: Results fromthe LIPID trial. Ann Intern Med 2001;134:931–940.8. Shepherd J, Blauw GJ, Murphy MB, et al. Pravastatinin elderly individuals at risk of vascular disease (PROS-PER): A randomised controlled trial. Lancet 2002;360:1623–1630. 9. Anum EA, Adera T. Hypercholesterolemia and coro-nary heart disease in the elderly: a meta-analysis. AnnEpidemiol 2004; 14:705–721.10. Schatz IJ, Masaki K, Yano K, et al. Cholesterol and all-cause mortality in elderly people from the HonoluluHeart Program: A cohort study. Lancet 2001;358:351–355.11. Brescianini S, Maggi S, Farchi G, et al. Low total cho-lesterol and increased risk of dying: Are low levels clin-ical warning signs in the elderly? Results from theItalian Longitudinal Study on Aging. J Am Geriatr Soc2003; 51:991–996. 12. Secondary Prevention of Coronary Heart Disease inthe Elderly (With Emphasis on Patients >=75 Years ofAge): An American Heart Association ScientificStatement From the Council on Clinical CardiologySubcommittee on Exercise, Cardiac Rehabilitation,and Prevention. Circulation 2002; 105:1735–1743. It is unclearwhether the benefits of statinsextend to theadvanced elderly(aged 80 years andolder)FAST TRACKJFP_0406_CI.FinalREV2  3/21/06  9:08 AM  Page 357

Should we identify and treat hyperlipidemia in the advanced elderly?

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