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BACK TO BACKstatins and 6/39 817 control patients (0.015%). 7Combining multiple trials found no consistentevidence that statins increased overall cancerrisk, or at any particular site, for any particularage group or by duration of treatment. 7 All-causemortality was reduced 7 allaying fears suggestedby a single trial re-analysis. 8Given that so many older patients alreadyhave CVD, it is also important to examinethe effect of statins in secondary prevention.A meta-analysis of nine secondary preventiontrials with almost 20 000 patients aged 65–82years reported a 22% reduction in all causemortality within five years of starting statins.Just under 30 patients required treatment toprevent one death. 9risk assessed in routine general practice. Justover one-third of these elderly have had a CVDevent, just under one-third are at high estimatedrisk (>15% five-year CVD risk) and theremaining third are at moderate or low estimatedrisk for whom lifestyle advice, not drugs,is recommended.In conclusion, people over 75 years with a fiveyearCVD risk of >15% and a healthy life expectancyof five years can substantially reduce theirrisk of CVD and all cause mortality by takingstatins and should all be offered this opportunityunless specifically contraindicated.‘The idea is to die young, as late as possible.’—Ashley MontaguA significant proportion of people with coronaryheart disease progress to congestive heart failurewhere QoL, as measured by symptom burden,depression, and spiritual well-being, is akin tothat of people with advanced cancersSome practical considerationsThere will always be a need to balance quality oflife and comorbidities (e.g. dementia, disability ormajor physical illnesses such as cancer, renal failureand COPD) along with exploring preventivecare possibilities. Adding a statin will contributeto polypharmacy. Therefore this needs to be partof the discussion. Life expectancy is also pertinent.If a man has survived to 75, 80 or 85 years,Statistics New Zealand estimate they will onaverage have a further 11, eight and six years—long enough to reap the full benefits of five yearsof statin treatment. Women fare slightly better(add a couple of extra years).Contrary to many beliefs, prescribing statinsto those over 15% CVD risk, will not resultin prescribing for all the over 75s. The NewZealand PREDICT cohort currently has about10 000 people over 75 years who have beenReferences1. World Health Organization. Global burden of disease. Deathand DALY estimates for 2004 by cause for WHO memberstates. Geneva: World Health Organization; 2009.2. Chan WC, Wright C, Riddell T, Wells S, Kerr AJ, Gala G,et al. Ethnic and socioeconomic disparities in the prevalenceof cardiovascular disease in New Zealand. N Z Med J.2008;121(1285):11–20.3. Bekelman DB, Rumsfeld JS, Havranek EP, Yamashita TE, HuttE, Gottlieb SH, et al. Symptom burden, depression, and spiritualwell-being: a comparison of heart failure and advancedcancer patients. J Gen Int Med. 2009;24(5):592–8.4. Terry DF, Sebastiani P, Andersen SL, Perls TT. Disentanglingthe roles of disability and morbidity in survival to exceptionalold age. Arch Int Med. 2008;168(3):277–83.5. Yates LB, Djousse L, Kurth T, Buring JE, Gaziano JM.Exceptional longevity in men: modifiable factors associatedwith survival and function to age 90 years. Arch Int Med.2008;168(3):284–90.6. de Ruijter W, Westendorp RGJ, Assendelft WJJ, den ElzenWPJ, de Craen AJM, le Cessie S, et al. Use of Framingham riskscore and new biomarkers to predict cardiovascular mortalityin older people: population based observational cohort study.BMJ. 2009;338:a3083.7. Baigent C, Keech A, Kearney PM, Blackwell L, Buck G,Pollicino C, et al. Efficacy and safety of cholesterol-loweringtreatment: prospective meta-analysis of data from 90,056participants in 14 randomised trials of statins. Lancet.2005;366(9493):1267–78.8. Packard CJ, Ford I, Robertson M, Shepherd J, Blauw GJ,Murphy MB, et al. Plasma lipoproteins and apolipoproteinsas predictors of cardiovascular risk and treatment benefit inthe PROspective Study of Pravastatin in the Elderly at Risk(PROSPER). Circulation. 2005;112(20):3058–65.9. Afilalo J, Duque G, Steele R, Jukema JW, de Craen AJM, EisenbergMJ. Statins for secondary prevention in elderly patients:a hierarchical bayesian meta-analysis. J Am Coll Cardiol.2008;51(1):37–45.332 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE
BACK TO BACKAll people over 75 years with a five-yearCVD risk of >15% should be treated withstatins unless specifically contraindicatedNOKey points• Cardiovascular risk estimates for youngerpeople do not work to predict outcomesin the same way for those over 75.• Statins do not work for primary prevention inpeople in this age bracket. Including secondaryprevention data indicates that they may simplyshift the cause of death and morbidity ratherthan improving the length of life or morbidity.• There is significant potential harmin indiscriminate prescribing.Suggesting all over–75-year-olds should be treatedwith statins is surely a John McEnroe ‘You cannotbe serious’ statement. There are a number of reasonswhy this idea is nonsense: In this age group,the absolute risk approach doesn’t work, the drugsdon’t work and there is potential for adding to theburden of morbidity rather than relieving it.Risk in older populationsIt is dangerous to infer benefit based on researchin younger populations. Risk tables cannot beapplied in the same way to older populations andthere is good evidence that cardiovascular riskoperates differently in older individuals. A studyusing the Framingham model has demonstratedthat in people over 85 years who had not developedcardiovascular disease, the classic risk factorsincluded in a Framingham risk score did not predictthose at high risk of cardiovascular mortalityin the way it does in younger populations. 1Estimates of absolute risk enable assessment ofpotential benefits of particular treatments inyounger populations. However, this approach isnot a good model in older age when the likelihoodof morbidity due to multiple and compoundingdiseases is increased. The absolute riskof dying of any one or more of these diseasesor in fact something completely different isincreased simply because the time of death isproportionately closer. This magnifies the apparenteffect of a single intervention for a specificcondition, despite overall survival being onlyminimally affected.This notwithstanding, preventive treatmentmight still be justified in terms of postponementof morbidity, even when there is nochange in mortality. The use of statins forprevention of cardiovascular disease in the elderlyprovides a case study for examining theseissues further.Evidence for lipid-loweringagents in older ageSo how effective are these drugs in the elderly?There is no evidence that giving statins to all patients>15% risk of CVD improves either quantityor quality of life in this age group—i.e. mortalityand morbidity are unaffected.There is only one large randomised controlledtrial, carried out in over 5000 70–82-year-olds,that highlights the effect of statins in primaryprevention in this age group.The data in this study revealed no demonstrablebenefit for pravastatin in primary prevention inthis group (Figure 1). A number of studies andanalyses have been produced (often sponsored bypharmaceutical companies), obscuring this lackof benefit over 75 by including those 65–75 yearsin the group of ‘older’ patients. Further obfusca-Derelie Mangin MBChBDPH, Department ofPublic Health andGeneral Practice,Christchurch Schoolof Medicine, Universityof Otago, Christchurch,New ZealandMangin D. All people over 75years with a five-year CVDrisk of >15% should be treatedwith statins unless specificallycontraindicated—the ‘no’case. J Prim Health Care.2010;2(4):333–335.VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 333
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