Highlights Unlike the attenuation of risk reduction in older people found in a meta-analysis, this Danish population-based study found no difference in the value of primary prevention in older people compared to those under 70 years of age. This could be related to misclassification of people labeled as without atherosclerotic vascular disease or on primary prevention. Importantly, the relative risk reduction was 23% per 1 mmol/L (~40 mg/dL), which is very similar to other population studies. The evidence found is useful for clinicians to consider LDL-C treatment for primary prevention in people ≥70 years of age, perhaps starting with a lower dose to test tolerance and titrating the dose to similar goals. The evidence is not adequate to consider the recommendations as evidence-based guidelines. |
Study questions:
Is there a difference in the clinical efficacy of lowering low-density lipoprotein cholesterol (LDL-C) with lipid-lowering therapy for the primary prevention of cardiovascular disease between older and younger people?
Methods:
The study was conducted in a Danish national cohort that included people aged ≥50 years who had started lipid-lowering treatment (statins alone or in combination) between January 1, 2008 and October 31, 2017 and had no history of cardiovascular disease. (no ASCVD hospitalization, use of nitrates, adenosine diphosphate inhibitors, or medications used for secondary prevention), and had a baseline measurement and LDL-C measurement within 1 year.
The associated risk of major vascular events among older persons (≥70 years) was determined using hazard ratios (HRs) per 1 mmol/L reduction in LDL-C compared with younger persons (<70 years).
Results:
For both the 16,035 older and 49,155 younger individuals, the mean LDL-C reduction was 1.7 mmol/L. Each 1 mmol/L reduction in LDL-C in older people was significantly associated with a 23% lower risk of major vascular events (HR, 0.77; 95% confidence interval [CI], 0.71-0. .83), which was the same as that of younger individuals (HR, 0.76; 95% CI, 0.71-0.80; p value for the difference was 0.79). Similar results were observed in all secondary analyses.
Conclusions: In a Danish nationwide cohort study, there is a similar relative clinical benefit of lowering LDL-C for the primary prevention of major vascular events in people aged ≥70 years as in people <70 years. |
Perspective:
The study was limited to new users of lipid-lowering therapy in routine clinical practice. Evidence from clinical trials of LDL-C-lowering treatments has shown that the relative risk of major vascular events is reduced by approximately 20% for every 1 mmol/L (~40 mg/dL) reduction in LDL-C, which is remarkably similar to the 23% decrease in this Danish population study.
Interestingly, the frequency of physicians prescribing low-, moderate-, and high-intensity lipid-lowering therapies was similar in the older and younger age groups. Limitations include the likelihood that a significant percentage of those defined as primary prevention had ASCVD.
