Clinical Edge

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Statin Treatment vs Usual Care in Older Adults

JAMA Intern Med; ePub 2017 May 22; Han, et al

When compared to usual care, no benefit was found when pravastatin was given for primary cardiovascular prevention to older adults with moderate hyperlipidemia and hypertension, a recent study found. Participants in the Lipid-Lowering Trial (LLT) component of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT-LLT) received either pravastatin (40 mg/d) or usual care (UC) from February 1994 to March 2002 at 513 clinical sites. Primary outcome was all-cause mortality; secondary outcomes included cause-specific mortality and nonfatal myocardial infarction (MI) or fatal coronary heart disease (CHD). Researchers found:

  • There were 1,467 participants in the pravastatin group and 1,400 participants in the UC group.
  • By year 6, the mean (SD) low-density lipoprotein cholesterol (LDL-C) levels were 109.1 mg/dL (35.4) in the pravastatin group vs 128.8 (27.5) mg/dL in the UC group.
  • Also at year 6, of the participants assigned to pravastatin, 42 of 253 (16.6%) were not taking any statin; 71.0% in the UC group were not taking any statin.
  • A nonsignificant trend toward increased all-cause mortality with pravastatin was observed among adults aged ≥75 years.
  • CHD event rates were not significantly different among the groups.

Citation:

Han BH, Sutin D, Williamson JD, et al; for the ALLHAT Collaborative Research Group. Effect of statin treatment vs usual care on primary cardiovascular prevention among older adults. The ALLHAT-LLT Randomized Clinical Trial. [Published online ahead of print May 22, 2017]. JAMA Intern Med. doi:10.1001/jamainternmed.2017.1442.

Commentary:

The recommendations for statin use are driven by 10-year risk of CV disease, and since age is a significant driver of that risk, it is not surprising that statins are commonly recommended for older patients. This is true even though the evidence of statin treatment benefit is only available for secondary prevention in older individuals. There is no data supporting a benefit on the primary prevention of CV disease in the elderly, that is the use of statins in patients who have not yet had a CV event.1 The official American Heart Association risk calculator is explicit in stating that it only calculates lifetime risk for patients currently up to age 59, and 10-year risk only up to age 79. That said, approximately one-third of patients over 80 years of age take statins for the primary prevention of cardiovascular disease.2 This study, whose patients had an average age of 71 years, provides direct evidence that there is no benefit to the use of statins for primary prevention of CV disease in this age group. —Neil Skolnik, MD

  1. Strandberg TE, Kolehmainen L, Vuorio A. Evaluation and treatment of older patients with hypercholesterolemia: a clinical review. JAMA. 2014;312(11):1136-44. doi:10.1001/jama.2014.10924.
  2. Johansen ME, Green LA. Statin use in very elderly individuals, 1999-2012. JAMA Intern Med. 2015;175(10):1715-1716. doi:10.1001/jamainternmed.2015.4302.