Statin Therapy in Elderly Patients with Peripheral Vascular Disease

Benefits of Continuation

The American Heart Association recommends that statin therapy be continued in elderly patients with peripheral vascular disease, as it provides substantial mortality and morbidity benefits regardless of age 1, 2, 3
Older patients with peripheral arterial disease benefit from cholesterol-lowering therapy, with studies showing increased treadmill walking time before onset of claudication at 6 and 12 months after statin initiation 2, 3
Discontinuing statins in patients with established atherosclerotic cardiovascular disease increases short-term mortality and major adverse cardiac events, although this fact is from a less preferred source, a better source is needed 4
The American College of Cardiology and the American Heart Association guidelines support the use of statin therapy in older adults with documented vascular disease, with a strength of evidence that is credible through about age 85 1, 3

In patients ≥65 years with coronary heart disease, statins reduced all-cause mortality by 22%, coronary heart disease mortality by 30%, non-fatal myocardial infarction by 26%, and stroke by 25%, although this fact is from a less preferred source, a better source is needed 4
Meta-analysis of 19,569 older coronary heart disease patients (65-82 years) showed a number needed to treat of 28 to save one life 2, 5
The absolute risk reduction is actually higher in older patients due to their elevated baseline risk, making the number needed to treat lower than in younger patients 5

Moderate-intensity statin therapy is recommended for patients >75 years with established cardiovascular disease, with atorvastatin 10-20 mg daily being the appropriate moderate-intensity dose, although this fact is from a less preferred source, a better source is needed 6, 4
High-intensity dosing (40-80 mg) should be avoided in very elderly patients due to increased adverse event risk without additional benefit, although this fact is from a less preferred source, a better source is needed 6
Target 30-40% LDL-C reduction from baseline rather than absolute targets in very elderly patients, although this fact is from a less preferred source, a better source is needed 6

Discontinuation should only be considered in specific circumstances, such as functional decline, severe frailty with limited life expectancy, multimorbidity with polypharmacy causing intolerable side effects, or age >85 years with concurrent severe frailty and comorbidities 3, 6
The American Geriatrics Society recommends considering discontinuation of statin therapy in patients with severe frailty or limited life expectancy, although this fact is not explicitly stated in the provided text, a better source is needed

The most common error is premature discontinuation based on age alone rather than functional status, although this fact is from a less preferred source, a better source is needed 4
Misperception of risks and benefits is the most common factor leading to non-adherence, with physician or patient preference accounting for 55% of discontinuation in clinical trials, although this fact is from a less preferred source, a better source is needed 4
Statins are notoriously under-prescribed and under-dosed in elderly patients despite their higher risk of recurrent events 1, 8

Assess adherence and LDL-C levels 4-12 weeks after any dose adjustment, although this fact is from a less preferred source, a better source is needed 6
Monitor for muscle symptoms at baseline, 6-12 weeks after starting therapy, and at each follow-up visit, although this fact is from a less preferred source, a better source is needed 7
Evaluate for drug interactions, particularly with polypharmacy common in elderly patients, although this fact is from a less preferred source, a better source is needed 6, 7
Consider dose reduction if two consecutive LDL-C values are <40 mg/dL, although this fact is from a less preferred source, a better source is needed 7