Benefit of Statins for Primary Prevention in Older Adults – The Gaps

The two questions I can absolutely count on being asked, as the geriatrician in a crowd of healthcare providers, are “should I start statins?” and “should I continue in those who are over 80?” I usually offer the uncomfortable answer, mirroring the conclusion of this 2018 JAGS review article, which is that we still do not have enough well-designed, rigorous studies to guide definitive best practice.

That said, this particular multidisciplinary expert panel convened by The National Institute on Aging and the National Heart, Lung and Blood Institute in 2018, succinctly outlined the specific deficiencies in our current knowledge. Looking at available evidence outlining the efficacy and safety of statins in primary prevention in those aged 80 and older, the panel pointed to the current age-limited AHA/ACC guidelines as evidence of a lack of definitive data.

The panel noted that current evidence for treatment in older adults not only comes from a combination of non-randomized studies, but most available RCTs have been underpowered to detect harms that are relevant to older adults.  For example, many of the populations often seen in long-term care settings, such as those with cognitive impairment, are not included in trials and there is a great variance in how cognitive outcomes are assessed. They also conclude that current data cannot just be extrapolated to older adults due to age-related differences, including physiological (renal function, muscle, body composition), functional (frailty, dementia) and systemic issues such as polypharmacy and time-to-benefit considerations (short-term risk of statins may outweigh long-term benefit).

Although the conclusion is unsatisfying (if not unanticipated), it is a worthwhile read if interested in specific recommendations related to the ideal design of studies that would help answer currently ambiguous questions.

Bottom line for post-acute care is that life-expectancy and time-to-risk (vs. -benefit) are important considerations when evaluating statin therapy. 


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