Statin Discontinuation in the Elderly Linked to More CV Events
More work is needed to determine which subgroups of patients older than 75 years can safely discontinue statins, experts say.
In elderly patients with no history of cardiovascular disease, statin discontinuation results in a 33% increased risk of hospital admission for cardiovascular events, according to new observational data.
Until now, “the role for statin therapy in primary prevention in the elderly remains a subject of debate, with little evidence for or against its benefit,” write lead author Philippe Giral, MD (Hôpital Pitié-Salpêtriére, Paris, France), and colleagues.
These findings are consistent with other observational data, but the study “adds to the literature by basically raising an alarm bell about what current practice is looking like and how there could be the risk signal with discontinuation of statins,” according to Seth Martin, MD (Johns Hopkins Medicine, Baltimore, MD), who was not involved in the study. “I definitely can see why folks would want to avoid polypharmacy and minimize the pill burden in older age, but the paradox is that this is exactly the group that may benefit the most—at that older end of the age spectrum where a lot of events are starting to occur.”
The results were published online July 30, 2019, ahead of print in the European Heart Journal.
For the study, researchers included all adults in France who turned 75 years old between 2012 and 2014 who had no history of cardiovascular disease and had been on statins for at least 2 years (n = 120,173). Over a mean 2.4-year follow-up, 14.3% of the cohort discontinued statins—defined as going 3 or more months without exposure—and 4.5% were admitted to the hospital with a cardiovascular event.
After adjustment, the risks of any cardiovascular event (HR 1.33; 95% CI 1.18-1.50) and coronary events (HR 1.46; 95% CI 1.21-1.75) were elevated in those who had discontinued statins. There did not seem to be an effect of statin discontinuation on other vascular events (HR 1.02; 95% CI 0.74-1.40). Interestingly, the trend seemed to continue past 75 years: 4 years after the 75th birthday, the cumulative incidence rate for CV events was 10.1% versus 7.6% in those who discontinued or continued statin therapy, respectively.
Subgroup analyses confirmed these findings in groups stratified by sex, diabetes, antihypertensive drug use, comorbidity burden, and frailty.
“Future studies, including interventional randomized studies, are needed to confirm these findings and support updating and clarification of guidelines on the use of statins for primary prevention in the elderly,” write Giral and colleagues.
In an email to TCTMD, Giral and senior author Joël Coste, MD (Hôpital Cochin, Paris, France), said they are specifically awaiting results of the STAREE trial, which is looking at atorvastatin therapy and its effect on CV event rates in a population of 70- to 75-year-olds in Australia. Until further data are available, they only recommend discontinuing statin therapy in elderly patients “with a severe comorbidity which may influence short-term survival.”
For Martin, it’s possible that statins could be discontinued safely in older patients “who really are healthy without traditional cardiovascular risk factors.” Even at 75 years, some patients present with a zero calcium score, he noted, adding that these might also be good candidates in whom to avoid statin therapy.
“Clearly statins are very safe drugs, and . . . when you have such safe drugs that work to lower LDL and reduce cardiovascular events, our tendency really should be to treat in a higher-risk group,” he said. “We're going to need to be more confident in evidence to not treat, and in that case, one of the best tests would be subclinical atherosclerosis imaging with coronary calcium.”
The fact that about one-third of patients in this study reported a CV event is something to take “very seriously,” Martin continued. “From a research standpoint, it means we need to do more to really figure out who can have safe discontinuation of statins. On the clinical front, when you're making that shared decision with your patient, you need to be very transparent about [the fact] that this may be the time where you benefit the most and really talk it through. And if you are going to discontinue, have a really good rationale to do so.”
Giral P, Neumann A, Weill A, Coste J. Cardiovascular effect of discontinuing statins for primary prevention at the age of 75 years: a nationwide population-based cohort study in France. Eur Heart J. 2019;Epub ahead of print.
- Giral and Coste report no relevant conflicts of interest.
- Martin reports receiving personal fees from Amgen, Sanofi, Regeneron, Esperion, Novo Nordisk, Quest Diagnostics, Akcea Therapeutics; receiving grants from Apple, Google, iHealth, Nokia, Maryland Innovation Initiative, American Heart Association, Aetna Foundation, PJ Schafer Memorial Fund, David and June Trone Family Foundation; and has a pending patent for a Method of LDL-C Estimation.