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Advanced Age and CV Risk: To Start or Not to Start a Statin in Older Patients?

  • Authors: Kausik K. Ray, MD, MPhil, FRCP; Lale Tokgözoğlu, MD, FACC, FESC
  • CME / CE Released: 9/25/2018
  • Valid for credit through: 9/25/2019, 11:59 PM EST
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This activity is intended for primary care physicians, cardiologists, diabetologists and endocrinologists, nurses, and pharmacists.

The goal of this activity is to improve understanding and clinical expertise regarding the use of statins in older patients.

Upon completion of this activity, participants will:

  • Have greater knowledge related to
    • Tailoring statin therapy in older patients to minimize risk for cardiovascular (CV) recurrence
    • Using appropriate team-based care to improve safety of statin therapy and drug-drug interactions in elderly patients


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  • Kausik K. Ray, MD, MPhil, FRCP

    Professor of Public Health
    Imperial College London
    London, United Kingdom


    Disclosure: Kausik K. Ray, MD, MPhil, FRCP, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: AbbVie Inc.; Amgen Inc.; Cerenis; Ionis; Lilly; Medco; Regeneron Pharmaceuticals, Inc.; Sanofi
    Served as a speaker or a member of a speakers bureau for: Alforithm; AstraZeneca Pharmaceuticals LP; Boehringer Ingelheim Pharmaceuticals, Inc.; CIPLA; Kowa Company Ltd.; Pfizer Inc.; Takeda Pharmaceuticals North America, Inc.
    Received grants for clinical research from: Amgen Inc.; Pfizer Inc.; Regeneron Pharmaceuticals, Inc.; Sanofi

    Dr Ray does not intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics approved by the FDA for use in the United States.

    Dr Ray does not intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.

  • Lale Tokgözoğlu, MD, FACC, FESC

    Professor of Cardiology
    Department of Cardiology
    Hacettepe University Faculty of Medicine
    Ankara, Turkey


    Disclosure: Lale Tokgözoğlu, MD, FACC, FESC, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: Amgen Inc.; Merck & Co., Inc.; Novartis Pharmaceuticals Corporation; Novo Nordisk; Recordati; Sanofi
    Served as a speaker or a member of a speakers bureau for: Abbott Laboratories; Amgen Inc.; AstraZeneca Pharmaceuticals LP; Bayer HealthCare; Mylan Laboratories Inc.; Novartis Pharmaceuticals Corporation; Recordati; Sanofi; SERVIER

    Dr Tokgözoğlu does not intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics approved by the FDA for use in the United States.

    Dr Tokgözoğlu does not intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.


  • Joy P. Marko, MS, APN-C, CCMEP

    Scientific Director, Medscape, LLC


    Disclosure: Joy P. Marko, MS, APN-C, CCMEP, has disclosed no relevant financial relationships

  • Katherine L. DeYoung, PhD

    DeYoung Medical Writing, LLC
    Savannah, GA


    Disclosure: Katherine L. DeYoung, PhD, has disclosed no relevant financial relationships

CME Reviewer / Nurse Planner

  • Amy Bernard, MS, BSN, RN-BC, CHCP

    Lead Nurse Planner, Medscape, LLC


    Disclosure: Amy Bernard, MS, BSN, RN-BC, CHCP, has disclosed no relevant financial relationships.

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Advanced Age and CV Risk: To Start or Not to Start a Statin in Older Patients?

Authors: Kausik K. Ray, MD, MPhil, FRCP; Lale Tokgözoğlu, MD, FACC, FESCFaculty and Disclosures

CME / CE Released: 9/25/2018

Valid for credit through: 9/25/2019, 11:59 PM EST


  • Advanced Age and CV Risk: To Start or Not to Start a Statin in Older Patients?

    • Slide 1.

      Slide 1.

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    • Definition of Elderly[1,2]

      • Patients are living longer and longer
      • The high proportion of cardiovascular disease (CVD) in the elderly is a huge problem

    • Slide 2.

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    • The Elderly and Vascular Disease[2,31]

      • Many comorbidities associated with older age, including CVD, renal disease, chronic obstructive pulmonary disease (COPD)
      • Focus for patients in 40s and 50s is myocardial infarction (MI); stroke becomes more important in the elderly
      • Prevention is clear (lifestyle modification, smoking cessation, etc), but risk factor reduction is less clear
      • Many question whether low-density lipoprotein (LDL) reduction, statin therapy are worthwhile in the elderly
      • HYVET trial clarified the benefit of treating hypertension in persons ≥80 years of age

    • Slide 3.

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    • Tailoring Lipid-Lowering Therapy in the Elderly

      • Slide 4.

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      • Statins: Highly Favorable Risk-Benefit Ratio[3]

        • Elderly patients often have muscle aches and pains, and may attribute them to therapy and stop taking their statin
        • In every age category, there are small risks associated with statin therapy
        • Cases of cognitive dysfunction have been reported in observational studies, but not in randomized controlled trials
        • Potential side effects cause concern in the patient

      • Slide 5.

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      • Highest Risk of Statin Toxicity[4,5]

        • Elderly are more prone to adverse events (AEs), and the likelihood of AEs should be evaluated before starting statins
        • Physiology starts to change after 80 years, so extra caution is warranted
        • These precautions apply to other drugs as well, not only to statins
        • Polypharmacy refers to prescription and over-the-counter medications
          • Elderly are heavy users of over-the-counter medications
          • It is not known how supplements, over-the-counter agents interact with statins

      • Slide 6.

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      • Polypharmacy and Drug-Drug Interactions[2,6]

        • In younger patients, high-dose simvastatin should not be used with calcium antagonists

      • Slide 7.

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      • Statin Pharmacokinetics[7]

        • Statins efficacious as a group, but have very different pharmacokinetics individually

      • Slide 8.

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      • Pitavastatin and Pravastatin: Less Likely to Interact With Common Medications in CV Care[8]

        • Statin treatments are lifelong, and a patient in their 80s may live another 5 to 10 years
        • Patients on statins should not be given macrolide antibiotics for a chest infection
        • Many medications cause dehydration

      • Slide 9.

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      • Common Drug Interactions With Statins[4]

        • Some newer oral anticoagulants can increase statin levels
        • Physicians tend to focus on the immediate problem, and patients will not remember every potential medication issue
        • Approach to choosing a statin: follow guidelines, start with low dose, and choose a statin not likely to have drug-drug interactions
        • Patient education handouts listing medications to beware of are useful
        • Physician education on co-prescribing is important
        • Pharmacists, nurses, and other healthcare professionals play an important role in preventing drug-drug interactions

      • Slide 10.

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      • PROSPER: Primary Endpoint[9]

        • Secondary prevention group benefited, as expected in a high-risk, elderly population
        • PROSPER trial is powered on overall treatment effect
        • About half the patients were primary prevention with a lower event rate, not expected to be statistically significant

      • Slide 12.

        Slide 12.

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      • Primary Prevention in the Elderly: MI and Stroke Reduced With Statins[10,32]

        • There is a clear case for primary prevention using statins in patients with established CVD, regardless of age, unless there is good reason not to use it
        • The argument against primary prevention in elderly individuals with no cardiovascular (CV) events discounts short-term risk
        • Primary prevention trials that showed no all-cause mortality benefit, like WOSCOPS, have been criticized
          • Over 3 years of follow-up, competing risks from infections, cancer deaths
          • Trends for CV mortality reduction are seen when strokes are reduced

      • Slide 13.

        Slide 13.

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      • JUPITER and HOPE-3 Trials[11-13]

        • Annualized event rate threshold was once 2% per year for statins
        • These contemporary trials show clear benefit of statins
        • Number needed to treat (NNT) relatively small compared with other studies because absolute risk is so high

      • Slide 14.

        Slide 14.

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      • STAREE: STAtins for Reducing Events in the Elderly[9,11,14]

        • The STAREE trial is enrolling in Australasia and will recruit in Europe
        • STAREE is using a more potent statin dose and a more modern statin than used in PROSPER, thus a bigger treatment effect is expected
        • The answers on primary prevention will not necessarily come from any 1 study
        • STAREE could be for primary prevention in the elderly what JUPITER (n=6801)was for primary prevention in women

      • Slide 15.

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      • Secondary Prevention (cont)[16-21]

        • PROVE-IT was conducted when people were still arguing about treatment goals
        • National Cholesterol Education Program (NCEP) low-density lipoprotein cholesterol (LDL-C) goal: 70 mg/dL
        • To choose the right therapy for this high-risk patient group, due consideration must be given to the different treatments, safety, and the reason for treatment

      • Slide 17.

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      • CTT Meta-Analysis[22]

        • Cholesterol Treatment Trialists' (CTT) Collaboration meta-analysis showed similar benefit, safety for ages ≤65, >65 to ≤75, and >75 years
        • Physicians should reassure patients that side effects are not permanent, can be relieved by dose reduction or switching to another statin

      • Slide 18.

        Slide 18.

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      • Guideline Recommendations: Statin Therapy in the Elderly (>75 years)[23,24,33]

        • European Joint National Committee (JNC) hypertension guidelines defined older populations differently, resulting in under-treatment in certain regions
        • US guidelines do not recommend an LDL-C treatment target
        • European guidelines do not distinguish elderly from general population, suggest treatment targets based on risk
          • LDL-C <70 mg/dL for very high risk
          • LDL-C <100 mg/dL for high risk

      • Slide 19.

        Slide 19.

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      • SCORE: Cardiovascular Disease Risk Estimation[24-26]

        • European guidelines have taken into account all evidence, not only randomized trials, as patients do not always fit into randomized trials
        • Treatment goals benefit patients and physicians
        • LDL-C <70 mg/dL should be the goal for patients with atherosclerotic vascular disease

      • Slide 20.

        Slide 20.

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      • REAL CAD Primary Endpoint: CV Death/MI/Ischemic Stroke/Unstable Angina[23-25,27,34]

        • Primary prevention is a challenge, and approaches differ in the US and Europe
          • Risk prediction by Pooled Cohort Equations in US, SCORE in Europe
          • US guidelines: no recommendation for primary prevention >75 years of age
          • European guidelines: number of risk factors, not age, determines therapy
        • Statins work, and every statin tested has a positive outcome trial in this patient group

      • Slide 21.

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      • Reassuring the Patient About Statins

        • The team-based approach is extremely important

      • Slide 23.

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      • 2015 ACC Health Policy Statement: Team Management[30]

        • Pharmacists can call the physician's attention to polypharmacy
        • The only way to success is to work together with the care team and the patient

      • Slide 24.

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      • Thank You




        This content has been condensed for improved clarity.

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