Marcellaud E, Jost J, Tchalla A, et al. Statins in Primary Prevention in People Over 80 Years. Am J Cardiol. 2023 Jan 15;187:62-73. doi: 10.1016/j.amjcard.2022.10.015. Epub 2022 Nov 29. (Systematic review)

In the much older population (=80 years), the management of cardiovascular diseases requires specific research to avoid a plain transposition of medical practice from younger populations. Whether statins are useful in primary prevention in this population is not clear. The 3 intricate issues requiring attention are (1) the impact of hypercholesterolemia on mortality and major adverse cardiovascular events in subjects >80 years, (2) the efficacy of statins to prevent cardiovascular events at this age, and (3) the safety and tolerance of statins in this population. Three systematic reviews were performed using a search on EMBASE, MEDLINE, Cochrane Central Register of Controlled Trials, and Web of Science databases including publication until January 2021. Among the 7,617 references identified, 29 were finally retained. Regarding the first objective (16 studies, 121,250 participants), 7 studies (10,241 participants) did not find total cholesterol and low-density lipoprotein levels associated with an increased rate of major cardiovascular events in octogenarians. A total of 6 studies (14,493 participants) found increased levels associated with events, whereas 3 studies (96,516 participants) found the opposite, with increased risk of major adverse cardiovascular events with lower levels of cholesterol. In 8 studies (436,005 participants) addressing the efficacy of statins, most did not indicate a significant decrease in the rate of major cardiovascular events in these subjects. Finally, regarding tolerance (9 studies, 217,088 participants), the most important side effects in this population were muscular, hepatic, and gastrointestinal disorders. These events were more frequent than in the younger population. In conclusion, in the absence of convincing evidence, the benefit of statins in primary prevention for much older patients is not certain. Their prescription in this setting should only be considered case by case, taking into consideration physiological status, co-morbidities, level of risk, and expected life expectancy. Specific trials are mandatory.

Discipline Area Score
Family Medicine (FM)/General Practice (GP) 6 / 7
General Internal Medicine-Primary Care(US) 6 / 7
Public Health 6 / 7
Endocrine 6 / 7
Internal Medicine 6 / 7
Cardiology 5 / 7
Comments from MORE raters

Cardiology rater

This metanalysis sheds light on treating atherosclerotic coronary artery diseases in octogenarians, an increasing population being highly underrepresented in clinical studies and not explicitly covered by the current guidelines. It further supports a patient-centered approach, taking into account overall health status, functional ability, and frailty, co-morbidities, level of risk, and expected life-expectancy when considering statin treatment in such patients.

Cardiology rater

This is a very informative article, particularly as we get to see many >80 year-olds with CAD. Highly relevant information.

Endocrine rater

Statins for primary prevention of cv diseases in octogenarians should be individualised.

Internal Medicine rater

Although this study could not provide the convincing evidence about benefits of statin use for primary prevention in older adults >80 years, I believe it is very valuable in that it definitely gave me some suggestions when considering statin use in daily practice.

Public Health rater

The authors should have provided rationale for why three separate systematic reviews were performed instead of one to answer the three research questions.

Public Health rater

A very relevant study. Contains three systematic reviews, that confirm the lack of evidence for a primary prevention of hypercholesterolemia in people over 80 years-old. Great impact on practice and health expenditures.
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