Statin Therapy in Elderly Patients with Coronary Artery Disease

Evidence and Recommendations

The American College of Cardiology recommends continuing statin therapy in elderly patients with established coronary artery disease, unless specific contraindications exist, as it provides substantial mortality and morbidity benefits 1
Discontinuing statins in patients with established CAD increases short-term mortality and major adverse cardiac events, with statin-adherent patients being half as likely to experience subsequent myocardial infarction compared to non-adherent patients 1
The American College of Cardiology suggests that for patients over 75 years with established CAD who are already tolerating statin therapy, continuation is reasonable after evaluating potential benefits, adverse effects, drug interactions, frailty, and patient preferences 2, 3
High-intensity statin therapy showed no heterogeneity of effect among age groups >75, >65 to ≤75, and ≤65 years in patients with ASCVD, with the ACC/AHA recommending moderate-intensity statin therapy for secondary prevention in adults aged 75 years or older with established CAD (Class IIa recommendation) 2, 4

Moderate-intensity statin therapy may be preferable in patients >75 years due to higher risk of adverse events, lower adherence, and higher discontinuation rates with high-intensity therapy, with moderate-intensity options including atorvastatin 10-20 mg, which typically reduces LDL-C by 30-50% 2, 4
The decision to continue or modify statin therapy should be based on expected benefit versus competing comorbidities, with consideration of drug interactions, particularly important in elderly patients on multiple medications 2, 4
Cognitive function should be monitored, as RCTs have not shown adverse effects of statin therapy on cognition, but liver function tests and muscle symptoms should also be monitored 2, 4

In patients ≥65 years with CHD, statins reduced all-cause mortality by 22%, CHD mortality by 30%, non-fatal MI by 26%, and stroke by 25%, with older adults having higher absolute risk and deriving greater absolute benefit from statin therapy 5, 6
Misperception of risks and benefits is the most common factor leading to non-adherence, with premature discontinuation at 1 month or 6 months being critical pitfalls to avoid, and physician or patient preference accounting for 55% of discontinuation in clinical trials 1