As the study asserts, the rationale for treating with statins as primary prevention is highly compelling in older adults, as aging itself is associated with high CV risk, and thus, statins seem a reasonable consideration. Nonetheless, there has been a lack of research regarding statins in the very old population (ie, adults aged 75 years or older). Ironically, many trials have specifically avoided enrolling very old adults precisely because they are so susceptible to age-related multimorbidity, polypharmacy, frailty and other complexities. Thus, there is a dearth of data pertaining to patients who are especially vulnerable to the diseases for which treatment is indicated and for which the study should be prioritized.
Therefore, this study is important as it tries to focus on the issue, and it is especially important as it focuses on very old adults with diabetes. Diabetes is an important dimension of the work as older adults are especially susceptible to it, and diabetes adds to CV risk, so the best care of diabetes is a priority. Treating elevated glucose aggressively in older adults with diabetes has not been shown to be effective, so understanding what is effective is particularly valuable for clinicians.
Diabetes adds to CV risk, and therefore treating with statins as primary prevention in a population with diabetes is very logical. It was a reasonable expectation that those with diabetes would benefit disproportionately, and it seems they did.
This study reinforces rationale to treat with statins in very old adults with diabetes with data that seem quite compelling through age 85. This makes sense conceptually.
The study falls short of saying anything with certainty regarding adults without diabetes. In other words, despite the fact the authors make the assertion that there was no benefit in those who did not have diabetes, this statement is flawed. First, there may be many other subsets of adults who benefit more than others that were not considered in this investigation. For example, it is known that patients with high calcium deposits in their hearts may benefit from primary statin prevention more than others; however, this study did not delineate differences among adults with this well-known index of added risk discrimination. It also did not consider the utility of higher doses of statins. The fact is that a higher dose of a statin may have more treatment benefit, but many older adults are only administered very low doses. For these and many other reasons, it is not accurate to say that statins only bring about benefit in those with diabetes, and/or that there are age cutoffs when treatment is no longer effective.
The fact remains, statins are not a panacea. There are compelling reasons to consider using them, but also reasons to consider not using them. On the “pro” side, they reduce CV events. Perhaps this can lower mortality, but even more important to many older adults is that they can reduce strokes and hospitalizations. Some data (in other studies) suggest they increase function and decrease frailty, which is a very important consideration for older adults. On the “con” side, statins add to risks of polypharmacy, they add to burden of cost, and they can cause myalgias. Some people assert they can add to confusion. Each aspect of the pros and cons remains somewhat controversial.
The NIH just released a plan to study primary prevention of statins in older adults. It is seen as an issue that needs much more study and insight than this retrospective cohort study can provide.
The authors emphasize a recent study that showed no benefit of primary statin therapy (Han BH, et al. JAMA Intern Med. 2017;doi:10.1001/jamainternmed.2017.1442), but that was a study based on data from the much older ALLHAT-LLT trial, which many have considered as an inherently flawed trial in that it was trying to analyze benefits of a relatively weak statin (pravastatin) when many of the people in the control arm ended up taking newer, more potent statins (particularly simvastatin) that were released during the time the study was in effect. Thus, the publication by Han and colleagues has been severely criticized.
Notably, another recent study not mentioned in this publication (Orkaby AR, et al. J Am Geriatr Soc. 2017;doi:10.1111/jgs.14993) did show benefit. This is exactly why the NIH is investing so much money to now study the issue more definitively.
Daniel E. Forman, MD
Chair, Section of Geriatric Cardiology
UPMC Heart and Vascular Institute
Disclosures: Forman reports no relevant financial disclosures.