Primary Prevention With Statin Therapy in the Elderly

Abstract

A, Numbers of individuals at risk, incidence rates, and hazard ratios for nonfatal myocardial infarction, nonfatal stroke, or cardio-vascular death in the JUPITER 2 and HOPE-3 3 primary prevention trials, stratified by age. B, Meta-analysis within age subgroups of the JUPITER 2 and HOPE-3 3 primary prevention trials evaluating the effects of rosuvastatin on the composite end point of nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death. CORRESPONDENCE were consistent across age groups, and a formal test for heterogeneity was nonsignificant. In HOPE-3, which had a longer average follow-up than JUPITER, rates of drug withdrawal in the rosuvastatin groups were 21.4%, 23.1%, and 29.1% among those <65, 65 to <70, and >70 years of age, respectively. In formal meta-analysis, a 26% relative risk reduc-tion was observed for those >70 years for the end point of nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death (HR, 0.74; 95% CI, 0.61–0.91; P=0.0048; Figure, bottom). For an expanded end point that also includes revascularization, effects were virtual-ly identical in those >70 years of age (HR, 0.74; 95% CI, 0.61–0.89; P=0.0016). In neither of these analyses was evidence of heterogeneity by age observed (P=0.10 and 0.19, respectively). The much higher event rates in those ≥70 years of age, along with the comparable relative rate reductions, imply larger absolute rate reductions associated with statin treatment and hence smaller numbers needed to treat to prevent an event in older compared with younger people. These contemporary trials reinforce evidence from smaller numbers of elderly primary prevention pa-tients enrolled in earlier statin trials. 5 Outcome data from JUPITER and HOPE-3 provide a starting point for discussions about statin use in primary prevention among the elderly. In our opinion, available data from existing trials support the use of statins in primary prevention among those ≥70 years of age. Our combined data do not, however, provide answers to all critical questions relevant for practice. Uncertain-ties remain with regard to hemorrhagic stroke, cognitive function, drug interactions, adherence, quality of life, and cost-effectiveness. Furthermore, despite the large sample sizes of JUPITER and HOPE-3, the number of individuals age ≥80 years is modest. Given the consis-tency of benefits for those >70 and <70 years of age, some benefit is likely even among those ≥80 years of age. This benefit, however, should be weighed against the potential for a modest impact on longevity and must take into account personal preferences with regard to the use of preventive measures.