Leya M, Stone N J
Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
Division of Cardiology; Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
Curr Atheroscler Rep. 2017 Oct 11;19(11):47. doi: 10.1007/s11883-017-0683-9.
Our aim was to examine the current evidence behind prescribing statins to individuals over 65 years of age with emphasis on those older than 75. Individuals over 75 years of age may often have multiple comorbidities and take many medications. Additionally, they are often underrepresented in randomized controlled trials (RCTs) of statins in older populations. While results of RCTs demonstrate the benefit of statin therapy in both primary and secondary prevention patients, clinicians must more carefully consider adverse effects and drug-drug interactions before prescribing statin therapy as well as determining the intensity in older individuals.
Four primary prevention trials support statins for primary prevention following a clinician-patient risk discussion. Of these, JUPITER and HOPE-3 studied participants 70 years of age and over who derived benefit. However, in those over 85 years, available information is inadequate to guide decisions regarding statin therapy. Documented statin adverse effects include new onset diabetes, myopathy, and medication interactions. Although cognitive decline has been reported anecdotally, its incidence was comparable to placebo in two RCTs with validated cognitive evaluations. Concerns about significant liver and kidney injury with statins were not corroborated in RCTs. For most patients, the potential for reducing ASCVD risk outweighs possible adverse effects; however, in the elderly, the impact of drug treatment on cognition, musculoskeletal ability, and independence must be heavily weighed. Given the limited high quality evidence for primary prevention in individuals over 75 years of age, neither the ACC-AHA nor USPSTF cholesterol guidelines recommend statin therapy for primary prevention in this patient population. If prescribed, physician judgment and shared decision-making are crucial. To aid clinicians, imaging studies of subclinical atherosclerosis may improve specificity of statin therapy to prevent ASCVD in the elderly in primary prevention.
我们旨在研究给65岁以上人群，尤其是75岁以上人群开具他汀类药物的现有证据。75岁以上的人群通常患有多种合并症，服用多种药物。此外，在老年人群他汀类药物的随机对照试验（RCT）中，他们的代表性往往不足。虽然RCT的结果表明他汀类药物治疗在一级和二级预防患者中均有益处，但临床医生在开具他汀类药物治疗以及确定老年个体的用药强度之前，必须更仔细地考虑不良反应和药物相互作用。
四项一级预防试验支持在临床医生与患者进行风险讨论后使用他汀类药物进行一级预防。其中，JUPITER试验和HOPE-3试验研究了70岁及以上的参与者，他们从中获益。然而，在85岁以上的人群中，现有信息不足以指导他汀类药物治疗的决策。已记录的他汀类药物不良反应包括新发糖尿病、肌病和药物相互作用。尽管有轶事报道称存在认知功能下降，但在两项经过验证的认知评估的RCT中，其发生率与安慰剂相当。RCT中并未证实对他汀类药物会导致严重肝损伤和肾损伤的担忧。对于大多数患者来说，降低动脉粥样硬化性心血管疾病（ASCVD）风险的潜力大于可能的不良反应；然而，在老年人中，必须充分权衡药物治疗对认知、肌肉骨骼能力和独立性的影响。鉴于75岁以上个体一级预防的高质量证据有限，美国心脏病学会（ACC）-美国心脏协会（AHA）和美国预防服务工作组（USPSTF）的胆固醇指南均不推荐在该患者群体中使用他汀类药物进行一级预防。如果开具了他汀类药物，医生的判断和共同决策至关重要。为帮助临床医生，亚临床动脉粥样硬化的影像学研究可能会提高他汀类药物治疗在一级预防中预防老年人ASCVD的特异性。
