Efficacy and safety of lowering LDL cholesterol in older patients: a systematic review and meta-analysis of randomised controlled trials

SPS commentary:

The relative risk was not statistically different for statin and non-statin treatment, and the benefit of LDL cholesterol lowering was observed for each component of the composite endpoint, including cardiovascular death (0.85 [0.74–0.98]), myocardial infarction (0.80 [0.71–0.90]), stroke (0.73 [0.61–0.87]), and coronary revascularisation (0.80 [0.66–0.96]).

A separate Danish cohort study found those aged 70–100 years with elevated LDL cholesterol had the highest risk of cardiovascular disease and the lowest estimated NNT in 5 years to prevent one event from use of a moderate-intensity statin.

A related commentary discusses this research, and recommends that although it is clear lipid lowering therapy is beneficial in older patients, physician judgment and shared decision making are needed to determine whether the benefit of lipid-lowering treatment in older patients for both primary and secondary prevention of cardiovascular disease will outweigh risk, taking into account functional status, independence, and quality of life. important for deciding on the need

 

It adds that although lipid-lowering therapy was efficacious in older patients, the benefit of treating individuals when they are younger should not be forgotten. The average age of patients in all the trials analysed was older than 60 years, an age when atherosclerotic cardiovascular disease is already well established. It suggests that lipid-lowering therapy should be initiated at a younger age, preferably before age 40 years, in those at risk to delay the onset of atherosclerosis rather than try to manage the condition once fully established or advanced. Somewhat modest reductions in LDL cholesterol from a younger age might result in much larger benefits over time. The older one is when one starts lipid-lowering therapy, the less likely one is to benefit during one’s lifetime because of the greater cumulative exposure to LDL cholesterol before initiation of therapy. Additionally, more intensive lipid-lowering therapy is required to achieve significant short-term cardiovascular benefit. It concludes that when to start lipid-lowering therapy and the duration of therapy are probably more important than whether to start lipid-lowering therapy, particularly for the primary prevention of cardiovascular disease in older patients, for whom further evidence is required.