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Evidence does not back primary CVD prevention with statins

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Evidence does not support the widespread use of statins in healthy older people to prevent heart disease and stroke, according to the authors of a new Spanish study.

Researchers said any primary protective effect from statins was limited to those with type 2 diabetes aged between 75 and 84.

“Patient preference remains the guiding principle while we wait for better evidence”

Aidan Ryan

Statins were not associated with a reduction in cardiovascular disease or death in healthy people aged over 75, the study found.

However, in those with type 2 diabetes, statins were related to a reduction in cardiovascular disease and death from any cause up to the age of 85 years.

As a result, the researchers said the findings from the study, led by the University of Girona, did not support the widespread use of statins for primary prevention in old and very old people.

But they did support treatment in selected people, such as those aged 75-84 years with type 2 diabetes, according to the researchers writing in the British Medical Journal.

Statin prescriptions to elderly patients have increased in recent decades, and trial evidence supports them for those aged 75 years or older with existing heart disease – known as secondary prevention.

“Old age itself puts people at increased risk of a heart attack or stroke”

Jeremy Pearson

But evidence on the effects of statins for older people without heart disease – known as primary prevention – is lacking, particularly in those aged 85 years or older and those with diabetes.

For the new study, the researchers assessed whether statin treatment is associated with a reduction in cardiovascular disease and death in old and very old adults with and without type 2 diabetes.

Using data from the Catalan primary care system database, they identified 46,864 people aged 75 years or more with no history of cardiovascular disease between 2006 and 2015.

Participants were grouped into those with and without type 2 diabetes and as statin non-users or new users who had started statins for the first time during the study enrolment period.

Primary care and hospital records were then used to track cases of coronary heart disease, angina, heart attack and stroke, and death from any cause over an average of 5.6 years.

In participants without diabetes, statin treatment was not associated with a reduction in cardiovascular disease or all-cause mortality in both old and very old age groups.

But in participants aged 75-84 years with diabetes, statins significantly reduced the incidence of cardiovascular disease by 24% and all-cause mortality by 16%. But the protective effect declined after age 85 and disappeared by age 90.

Although an observational study, it was a high quality and with a large sample size, reflecting real life clinical conditions, noted the researchers.

A such, they conclude that their results do not support the widespread use of statins in old and very old populations, but they do support treatment in those with type 2 diabetes younger than 85 years.

In a linked editorial in the same journal , Aidan Ryan at University Hospital Southampton and colleagues said the biggest challenge for clinicians was how to stratify risk among those aged more than 75.

They said that “patient preference remains the guiding principle while we wait for better evidence”.

King's College London

Professor Jeremy Pearson

Jeremy Pearson

Professor Jeremy Pearson, associate medical director at the British Heart Foundation, said: “Old age itself – particularly reaching the age of 80 and above – puts people at increased risk of a heart attack or stroke.

“Regardless of age, those who have suffered a heart attack or stroke will benefit from taking a statin,” he said in relation to secondary prevention.

On primary prevention, he said: “Previous clinical trials – which are a better measure than observational studies like this – have also suggested that statins can contribute to a reduction in risk of a heart attack or stroke in elderly people who are not at significant risk of heart disease.”

The “most important thing” was for primary care clinicians to “have a discussion with their elderly patients to help them understand their personal risk”, so they could make an “informed decision” about taking statins.

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