Is One Ever Too Old to Lower the Serum Cholesterol?
Abstract & Commentary
Synopsis: It would appear to be prudent to lower elevated serum cholesterol levels in elderly patients, especially those who are at high risk or who are afflicted with established atherosclerotic coronary artery heart disease and probably even in those without clinically manifest coronary artery heart disease.
Source: Grundy SM, et al for the Coordinating Committee of the National Cholesterol Education Program. Arch Intern Med 1999;159:1670-1678.
Over the past 15 years, major advances have been made in defining the role of elevated serum cholesterol as a risk factor for coronary artery heart disease. These studies were performed mostly on patients 70 years and younger and the results were so positive that the National Cholesterol Education Program (NCEP) now strongly promotes a variety of public health and clinical strategies for the reduction of high-serum cholesterol levels among all Americans.
It should be noted that several prospective epidemiologic studies have suggested that an elevated-serum cholesterol may be a relatively poor indicator of coronary heart disease in older individuals. On the other hand, Grundy and associates on the Coordinating Committee of the National Cholesterol Education Program reviewed the available evidence and concluded that the elderly, the population older than the age of 65, have not only the highest burden of atherosclerotic heart disease but also have the highest risk for the development of symptomatic coronary artery disease. They cited the recent clinical trials of cholesterol-lowering therapy with statin drug, which all demonstrated similar benefits in older as well as in younger patients.1-5 These clinical trials strongly justify using cholesterol-lowering therapy in a secondary prevention regimen especially in the "younger-elderly" (e.g., 65-75 years of age) patients, but the question as to whether such therapy is indicated in the "older-elderly" patients (e.g., > 75 years) remains to be addressed.
comment by Harold L. Karpman, MD, FACC, FACP
It has become increasingly clear that the elderly population of patients older than the age of 65 deserve special diagnostic and treatment considerations since the frequency of cardiac illnesses in this group of patients is the highest of any age group and coronary artery heart disease is the foremost cause of morbidity and mortality in these patients. It is well known that the chronological age of elderly people may differ significantly from their functional age. At one extreme are vigorous, independent, and physiologically robust individuals in their 80s or even 90s who participate in tennis and golf tournaments, visit their gyms on a daily basis, and who are frequently more fit and resilient than the majority of much younger people. On the other hand, many unfortunate "older- elderly" patients are afflicted with multisystem disease processes and are hampered by limited cardiovascular and respiratory reserves. To date, no clinical trial data are available to exactly define which sub groups of the "older-elderly" individuals with coronary artery heart disease will benefit from aggressive cholesterol management and, therefore, decisions are frequently based solely on the overall health status of each individual in this particular subgroup of patients. However, since the "older-elderly" group carries the highest risk and burden of coronary artery heart disease, it would appear to be unwarranted to withhold cholesterol-lowering therapy from both the fit, vigorous, and motivated group and possibly even from the elderly individuals with multisystem disease. Aggressive cholesterol-lowering in older patients with established atherosclerotic coronary artery heart disease appears to be fully justified and, in fact, such therapy is probably indicated for high-risk patients without clinically manifest atherosclerotic disease.
As always, the first line of primary prevention is lifestyle change with dietary therapy, regular physical exercise, weight control, eliminating cigarette smoking, stress management, etc., and drug therapy should definitely be considered for all patients at high risk. The Expert Panel on Detection, Elevation, and Treatment of High Blood Cholesterol in Adults6 recommends that the same guidelines be used for the management of high-serum cholesterol in both elderly men and women. Post-menopausal women with high cholesterol levels should be considered for estrogen replacement therapy although the results of recent statin trials that have included women1-3 suggest that cholesterol-lowering drugs should be used instead of or along with estrogens, especially by high-risk women in whom drug therapy is considered necessary to lower the cardiac risk profile.
The results from clinical trials, which are currently underway, that primarily recruit elderly patients should provide more specific data on the relative benefits of cholesterol-lowering in elderly populations. Of course, risk factor modification should always be aggressively addressed in all patients and, for the time being, it would appear to be prudent to lower elevated serum cholesterol levels in elderly patients, especially those who are at high risk or who are afflicted with established atherosclerotic coronary artery heart disease and probably even in those without clinically manifest coronary artery heart disease.
References
1. Scandinavian Simvastatin Survival Study Group. Lancet 1994;334:1383-1389.
2. Sacks FM, et al for the Cholesterol and Recurrent Events Trial Investigators. N Engl J Med 1996; 335:1001-1009.
3. The Long-Term Intervention with Pravastatin in Ischemic Disease (LIPID) Study Group. N Engl J Med 1998;339:1349-1357.
4. Petersen TR, et al. Circulation 1995;92(suppl 1):672.
5. Lewis SJ, et al. Ann Intern Med 1998;129:681-689.
6. Expert Panel on Detection, Education, and Treatment of High Blood Cholesterol in Adults. Circulation 1994;89:1329-1445.
The Expert Panel on Detection, Education and Treatment of High blood cholesterol in Adults recommends that high cholesterol levels in elderly men and women:
a. Need not be treated because of their advanced age and expected longevity.
b. Be treated with the same quidelines as applied to patients younger than the age of 65.
c. Be treated with only estrogen in women and with careful observation in men.
d. None of the above
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content