The requirement to respect autonomy - The Royal New Zealand ...

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