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In addition, on the basis of the recently published Heart Outcomes Prevention Evaluation (HOPE)-3 study, a broader group of patients in the IR category might gain benefit from statin therapy. The study included men 55 years of age and older, and women 65 years of age and older, with 1 additional risk factor. There was a demonstrated reduction in CVD events with rosuvastatin 10 mg daily regardless of LDL-C levels
Improved Reduction of Outcomes: Vytorin Efficacy International Trial (IMPROVEIT),61 in which patients with a recent acute coronary syndrome were treated for an average of 7 years, indicates that the combination of ezetimibe with moderate intensity statin therapy reduces LDL-C levels and CVD events. In this trial, LDL-C was decreased to < 2 mmol/L (average in-trial LDL-C level achieved with statin monotherapy and statin with ezetimibe were 1.8 mmol/L and 1.4 mmol/L, respectively). Thus, this provides further evidence for more aggressive LDL-C-lowering in high-risk patients. However, we acknowledge that more aggressive LDL-C-lowering with other nonstatin lipid-lowering therapies have not resulted in a reduction in CV events.
STATINS IN THE ELDERLY FEB 2018
The recommendations for statin therapy in elderly >65 years of age differ substantially among the 5 major guidelines currently used in North America and Europe.
At one end of the spectrum, the 2016 ESC/EAS guidelines miss great opportunities for safe, cheap, and evidence-based prevention in elderly individuals 66 to 75 years of age.
At the other end of the spectrum, the 2014 NICE guideline provides near-universal treatment recommendations well into the very elderly >75 years of age where RCT evidence is sparse and more uncertain.
The Framingham Risk Score for general cardiovascular disease (FRS-CVD) is not well validated after 75 years of age.
All of the current guidelines agree on age 40-65.
For age 65-75, only ESC doesnt push primary prevention
For Age > 75, only NICE strongly advocates primary prevention
evidence of efficacy for primary prevention with statins is sparse in this age group, as only few have been included in RCTs
Efficacy of statin therapy in the very elderly, however, is well documented in secondary prevention trials.
The STAREE (STAtins for Reducing Events in the Elderly) trial, a primary prevention trial currently underway, recruits individuals ≥70 years of age to determine efficacy and safety of statin treatment in elderly people.
Until more evidence is available for those individuals >75 years of age, initiation of primary prevention with statins in this age group must be based on well-informed shared decision making.
The primary efficacy end point was the composite of cardiovascular death, myocardial infarction, stroke, hospitalization for unstable angina, or coronary revascularization. The key secondary efficacy end point was the composite of cardiovascular death, myocardial infarction, or stroke.
The median duration of follow-up was 2.2 years.
reduced the risk of the primary end point (1344 patients [9.8%] vs. 1563 patients [11.3%];P<0.001) and the key secondary end point (816 [5.9%] vs. 1013 [7.4%]; ; P<0.001).
There was no difference in the likelihood of cardiovascular death (1.8% for evolocumab vs 1.7% for placebo) or all-cause mortality (3.2% vs 3.1%).
The bulk of the benefit came from fewer nonfatal MIs (3.4% vs 4.6%; P < .001; NNT = 83 over 26 months)
and a small decrease in nonfatal stroke (1.5% vs 1.9%; P = .01; NNT = 250 over 26 months).
reduction in LDL cholesterol levels was 59%, from a median baseline value of 92 mg per deciliter (2.4 mmol per liter) to 30 mg per deciliter (0.78 mmol per liter) (P<0.001).