Statin Use and All-Cause and Cardiovascular Mortality in US Veterans ≥75 Years
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Should we Start Statin Therapy in Someone Over the Age of 75 Years?
The instinctive response is that starting a statin at that age does not make sense because you need time to reap the benefits and it is too late for them. Also, there are very few studies in this age category so there is no evidence that it will work. Even the authors of this study points out that in the statin trials which included over 160,000 patients, less than 2% of the participants were over the age of 75 years. In fact in the current climate, many are advocating deprescribing in this age bracket as opposed to starting new therapies.
However, the elderly population is growing at an extremely fast rate as the baby boomers enter this bracket. Can we protect them from having a heart attack or stroke or dying prematurely with statin therapy? It is unlikely that we will be able to do a randomized placebo-controlled trial in this population. The next best thing is to look at real-world data to see if there are benefits of starting a statin in patients over the age of 75 years.
This research group searched the US Veterans Health Administration (VHA) services database and they found 326,981 veterans who over the age of 75 years who did not have ASCVD at baseline (primary prevention) and had a complete medical record. Of these 326,981 veterans, 57,178 (17.5%) were new statin users and the rest never had a statin prescription.
The mean age was 81.1 (range, 75-107) years, with 91.0% being white and 97.3% being men. The most common statin was simvastatin at 84.8% then lovastatin at 11.0%, and the more modern statins, atorvastatin and rosuvastatin, were only 0.5% of the statin users.
The mean follow-up for this study was 6.8 years (SD, 3.9) and there were 206,902 deaths, of which 53,296 were cardiovascular deaths. After propensity score matching, the statin user group was associated with 25% less all-cause mortality (HR, 0.75; 95% CI, 0.74-0.76; P < .001) and 20% less cardiovascular death (HR, 0.80; 95% CI, 0.78-0.81; P < .001).
Also, there were 123,379 ASCVD events, which included myocardial infarction, ischemic stroke, or CABG/PCI. The statin group was associated with an 8% reduction in ASCVD events (HR, 0.92; 95% CI, 0.91-0.94; P < .001). CABG/PCI, on its own, was significantly reduced by 11% (HR, 0.89; 95% CI, 0.88-0.91; P < .001).
In the subgroup analysis evaluating death outcome, there was benefit regardless of age. Even patients older than 90 years at baseline experienced benefit. Even in patients who had dementia, there was a death benefit.
These data are not as strong as a true randomized trial, but in all honesty, it is very unlikely that there will ever be a randomized, placebo-controlled trial of statin use in patients over the age of 75 years. This study provides the best data that we can get, and it is quite clear that starting a statin, even in the older age categories, has benefits in hard outcomes such as death and ASCVD events. There are very few things that we do that can reduce death in the elderly population, so no more debating. Let’s just protect the elderly from dying and from ASCVD—just do it.
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