Lipid lowering for secondary prevention of cardiovascular disease in older adults

A perceived lack of evidence for benefit and safety concerns may lead to underprescription of HMG-CoA reductase inhibitors (statins) in older adults. This article reviews clinical data regarding the effect of lipid-lowering therapies on cardiovascular outcomes in older adults with a focus on secondary prevention and safety considerations in this population. A literature search of the PubMed database (January 1984 to April 2009) was performed using search terms that included: 'aged' (MeSH heading), 'elderly', 'anticholesteremic agents', 'antilipemic agents', 'hydroxymethylglutaryl-CoA reductase inhibitors', 'cardiovascular diseases', 'randomized controlled trial', 'meta-analysis' and 'drug safety'. Results from large, randomized, controlled trials show that statin therapy lowers both all-cause and coronary heart disease mortality and reduces myocardial infarction, stroke and the need for revascularization in individuals aged ≥65 years who have a history of coronary heart disease. Given the high rate of recurrent cardiovascular events in older adults, there is substantial potential for statin treatment to provide benefits in this population. When older patients are prescribed statins, attention should be given to potential drug interactions, age-related changes in drug pharmacokinetics, adverse effects such as myopathy and risks arising from co-morbid conditions. Additional studies on the benefits and risks of lipid-lowering therapy in individuals aged ≥70 years who have no history of cardiovascular disease, and particularly in those aged ≥80 years, are needed. Other available lipid-modifying drugs - bile acid sequestrants (bile acid binding protein modulators), ezetimibe, niacin and fibrates (fibric acid derivatives) - may be required in patients who are statin-intolerant or have mixed dyslipidaemia, or in whom standard doses of statins may not be sufficient to achieve low-density lipoprotein cholesterol goals.