[Value and role of lipid lowering therapy for cardiovascular prevention in the elderly]

Most of elderly people die of coronary and cerebrovascular disease events or become disabled after non fatal stroke or dementia. Most of evidence of benefits shown in both primary and secondary prevention comes from randomized trials done on middle-aged men. The elderly population exposed to major cardiovascular events and dementia regularly increase due to the lengthening of life expectancy. If the benefit of anti-hypertensives agents is now well-established in isolated systolic hypertension in the elderly, evidence of efficacy with statins remained unclear and needed to be investigated. Observational studies and post-hoc analysis of randomized trials have raised the possibility that statins could reduce the rate of cardiovascular events and the rate of dementia in elderly individuals. In this setting occur the results of two recent trials investigated the effects of simvastatin in a high cardiovascular risk population of whom 30% were aged 70 or older (Heart Protection Study), or the effects of pravastatin for primary or secondary prevention in high risk elderly patients with a middle-age of 75 (Prosper). Major cardiovascular events are significantly reduced in both trials but the relative risk reduction is lower than in previous trials in middle-aged patients. In Prosper, the most beneficial group of patients are those with baseline HDL cholesterol under 0.40 g l-1 (1.1 mmol l-1); coronary heart disease events is the principal component of treatment benefit whereas cerebrovascular events are not significantly reduced at 3-years follow-up probably due to the short duration of the trial. The outcome do not provide evidence for benefit in dementia. However, there is a non significant trend to reduction of transient ischaemic attacks. Recent publications suggest that stroke benefit from statins does not begin to appear until after 3 years of treatment. Hence, those evidence suggests that the strategy for vascular risk management in middle aged people should also be applied to elderly individuals with a greatest benefit in the subgroup with the lowest HDL cholesterol.