Clinical Review

Management of Dyslipidemia in the Elderly

Journal of Clinical Outcomes Management. 2018 July;25(7):311-322

Author(s):

References

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From the Harrison School of Pharmacy, Auburn University, Mobile, AL.

Abstract

Objective: To summarize the literature relevant to managing dyslipidemia in the elderly and review recommendations for initiating lipid-lowering therapy.
Methods: Review of the literature.
Results: Statins are the most commonly utilized medication class for lipid-lowering in the general population, and they are recommended for primary prevention in patients between the ages of 40 to 75 with at least 1 risk factor for cardiovascular disease as well as for any patient needing secondary prevention. In the elderly, statins may be appropriate for both primary and secondary prevention if the benefits outweigh the risks. Based on the available evidence, it is safe to recommend statin therapy to elderly patients who require secondary prevention given the known benefits in reducing cardiovascular morbidity and mortality for patients up to the age of 80. For primary prevention, statin therapy may be beneficial, but one must carefully evaluate for comorbid conditions, life expectancy, concomitant medications, overall health status, frailty, and patient or family preference. Several other classes of lipid-lowering agents exist; however, there is not enough evidence for us to recommend use in the elderly population for cardiovascular risk reduction in either primary or secondary scenarios.
Conclusion: Although clinical research in the elderly population is limited, evidence supports the use of statins in elderly patients for secondary prevention and in patients up to age 75 for primary prevention; however clinicians must use clinical judgement and take into consideration the patient’s situation regarding comorbidities, polypharmacy, and possible adverse effects. More high-quality evidence is necessary.

Key words: hyperlipidemia; geriatrics; elderly; patient-centered care; statin; cardiovascular disease.

The number of Americans age 65 years and older is projected to more than double, from 46 million today to over 98 million by 2060, and the 65-and-older age group’s share of the total population will rise to nearly 24% [1]. Life expectancy is now predicted to be > 20 years for women at age 65 and > 17 years for men at age 65 in many high-income countries, including the United States [2]. This demographic shift toward an older population will result in a higher burden of coronary heart disease and stroke, with atherosclerotic cardiovascular disease (ASCVD) prevalence and costs projected to increase substantially [3].

Among adults seeking medical care in the United States, roughly 95 million have a total cholesterol (TC) level of ≥ 200 mg/dL or more, and approximately 29 million have a TC > 240 mg/dL [4]. Cholesterol screening is important since most patients suffering from dyslipidemia are asymptomatic. Dyslipidemia is a major risk factor for the development of atherosclerotic disease. Because of the complications associated with dyslipidemia, it is vital that patients are provided with primary and/or secondary prevention strategies to reduce the risk of cardiovascular disease (CVD) and protect high-risk patients from recurring events. A clinical controversy exists surrounding the elderly population, concerning whether or not clinicians should be providing lipid-lowering treatment to this group of individuals for dyslipidemia. The evidence is limited for patients over age 65, and even more so for the very elderly (> 80 years); therefore, it is necessary to review the available evidence to make an appropriate decision when it comes to managing dyslipidemia in the elderly population

Currently, HMG-CoA reductase inhibitors (statins) are the only known class of medications for the treatment of dyslipidemia that will prevent both primary and secondary cardiovascular (CV) events, including death. Statin intensity (Table 1)

is defined by low-density lipoprotein cholesterol (LDL-C)–lowering potential, and the majority of their use in clinical practice is based upon calculated risk for patients between the ages of 40 and 75 [5,6]. Several studies suggest that patients over the age of 75 should be treated accordingly [7,8]. Because of this evidence, recommendations for lipid-lowering therapy have been extrapolated to patients over the age of 75 in some treatment guidelines that currently recommend the use of statin therapy for elderly patients with dyslipidemia [9,10]. However, there are several concerns with providing therapy to the elderly, particularly those who have not experienced a CV event. In this review, we focus on the available evidence and provide recommendations for dyslipidemia management in patients over 65. Our aim is to aid in the clinical decision-making process, particularly for those practicing in the primary care setting.

Guideline Recommendations

Current guidelines differ in their recommendations for treating dyslipidemia in the elderly population. In 2016, the Task Force for the Management of Dyslipidemias of the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS) released updated guidelines for managing dyslipidemia. These guidelines recommend that older patients with established CVD be treated in the same way as younger patients because of the many benefits statin therapy demonstrated in clinical trials. They also suggest that statin therapy be started at a lower doses to achieve goals for primary prevention in the older population. In addition, CVD risk factors (hypertension, diabetes, dyslipidemia, smoking) should be addressed in this population to reduce CVD risk. They also acknowledged that primary prevention may not prolong life in the older adult, but treatment does reduce cardiovascular mortality and statin therapy is recommended to reduce the overall risk of CV morbidity in this population [11]. In contrast, The 2013 American College of Cardiology/American Heart Association (ACC/AHA) guidelines changed the management and treatment of dyslipidemia by highlighting “statin benefit groups” rather than recommending a treat-to-target goal as guidelines had done for many years. ACC/AHA recommends a moderate-intensity statin for patients > 75 years of age for secondary prevention versus the use of a high-intensity statin for patients who are between the ages of 40 and 75 based on the pooled cohort risk equation. In patients over age 75 with no history of CVD, no specific recommendation is available for the use of lipid-lowering therapy at this time [12]. ACC/AHA is expected to publish a new set of guidelines sometime in 2018 and they are projected to utilize lipid-lowering goals in combination with the pooled cohort equation to assess overall risk in patients with dyslipidemia.