Lipid-lowering treatment to the end? A review of observational studies and RCTs on cholesterol and mortality in 80+-year olds

Designing a tool ensuring older patients the right medication at the right time after discharge from hospital- the first step in a participatory design process

BACKGROUND

On average, older patients use five or more medications daily, increasing the risk of adverse drug reactions, interactions, or medication errors. Healthcare sector transitions increase the risk of information loss, misunderstandings, unclear treatment responsibilities, and medication errors. Therefore, it is crucial to identify possible solutions to decrease these risks. Patients, relatives, and healthcare professionals were asked to design the solution they need.

METHODS

We conducted a participatory design approach to collect information from patients, relatives, and healthcare professionals. The informants were asked to design their take on a tool ensuring that patients received the correct medication after discharge from the hospital. We included two patients using five or more medications daily, one relative, three general practitioners, four nurses from different healthcare sectors, two hospital physicians, and three pharmacists.

RESULTS

The patients' solution was a physical location providing a medication overview, including side effects and interactions. Healthcare professionals suggested different solutions, including targeted and timely information that provided an overview of the patient's diagnoses, treatment and medication. The common themes identified across all sub-groups were: (1) Overview of medications, side effects, and diagnoses, (2) Sharing knowledge among healthcare professionals, (3) Timely discharge letters, (4) Does the shared medication record and existing communication platforms provide relevant information to the patient or healthcare professional?

CONCLUSION

All study participants describe the need for a more concise, relevant overview of information. This study describes elements for further elaboration in future participatory design processes aimed at creating a tool to ensure older patients receive the correct medication at the correct time.

Ceramides improve cardiovascular risk prediction beyond low-density lipoprotein cholesterol

Aims

Low-density lipoprotein cholesterol (LDL-C) is the best documented cardiovascular risk predictor and at the same time serves as a target for lipid-lowering therapy. However, the power of LDL-C to predict risk is biased by advanced age, comorbidities, and medical treatment, all known to impact cholesterol levels. Consequently, such biased patient cohorts often feature a U-shaped or inverse association between LDL-C and cardiovascular or overall mortality. It is not clear whether these constraints for risk prediction may likewise apply to other lipid risk markers in particular to ceramides and phosphatidylcholines.

Methods and results

In this observational cohort study, we recorded cardiovascular mortality in 1195 patients over a period of up to 16 years, comprising a total of 12 262 patient-years. The median age of patients at baseline was 67 years. All participants were either consecutively referred to elective coronary angiography or diagnosed with peripheral artery disease, indicating a high cardiovascular risk. At baseline, 51% of the patients were under statin therapy. We found a U-shaped association between LDL-C and cardiovascular mortality with a trough level of around 150 mg/dL of LDL-C. Cox regression analyses revealed that LDL-C and other cholesterol species failed to predict cardiovascular risk. In contrast, no U-shaped but linear association was found for ceramide- and phosphatidylcholine-containing markers and these markers were able to significantly predict the cardiovascular risk even after multivariate adjustment.

Conclusion

We thus suggest that ceramides- and phosphatidylcholine-based predictors rather than LDL-C may be used for a more accurate cardiovascular risk prediction in high-risk patients.

Sex differences in lipids: A life course approach

Differences between men and women in lipids and lipoproteins are observed in distribution and trajectory from infancy to adulthood in the general population. However, these differences are more pronounced in hereditary lipid disorders such as familial hypercholesterolemia (FH) when absolute cholesterol levels are higher from birth onwards. In the early life course, girls compared to boys have higher low-density lipoprotein cholesterol (LDL-C) levels and total cholesterol, while high-density lipoprotein cholesterol (HDL-C) levels are similar. In early adulthood to middle-age, women have lower LDL-C and higher HDL-C levels, as LDL-C levels increase and HDLC levels decrease in men. In the elderly, all lipids - total cholesterol, LDL-C, HDL-C and triglyceride levels decrease but are more pronounced in men. Lipid levels are also affected by specific transitions in girls/women such as the menstrual cycle, pregnancy, breastfeeding and menopause. Lipid levels fluctuate during the menstrual cycle. During pregnancy a physiological increase of LDL-C and even a larger increase in triglyceride levels are observed. Pregnancy has a double impact on LDL-C accumulation in women with FH as they have to stop statins, and the absolute increase in LDL-C is higher than in women without FH. In the menopausal transition, women develop a more adverse lipid profile. Therefore, it is important to take into account both sex and the life course when assessing a lipid profile.

Handling polypharmacy -a qualitative study using focus group interviews with older patients, their relatives, and healthcare professionals

BACKGROUND

On average, older patients use five or more medications daily. A consequence is an increased risk of adverse drug reactions, interactions, or medication errors. Therefore, it is important to understand the challenges experienced by the patients, relatives, and healthcare professionals pertinent to the concomitant use of many drugs.

METHODS

We conducted a qualitative study using focus group interviews to collect information from patients, relatives, and healthcare professionals regarding older patients' management of prescribed medicine. We interviewed seven patients using five or more medications daily, three relatives, three general practitioners, nine nurses from different healthcare sectors, one home care assistant, two hospital physicians, and four pharmacists.

RESULTS

The following themes were identified: (1) Unintentional non-adherence, (2) Intentional non-adherence, (3) Generic substitution, (4) Medication lists, (5) Timing and medication schedule, (6) Medication reviews and (7) Dose dispensing/pill organizers.

CONCLUSION

Medication is the subject of concern among patients and relatives. They become confused and insecure about information from different actors and the package leaflets. Therefore, patients often request a thorough medication review to provide an overview, knowledge of possible side effects and interactions, and a clarification of the medication's timing. In addition, patients, relatives and nurses all request an indication of when medicine should be taken, including allowable deviations from this timing. Therefore, prescribing physicians should prioritize communicating information regarding these matters when prescribing.

Atrial fibrillation incidence and outcomes in two cohorts of octogenarians: LiLACS NZ

BACKGROUND

Atrial fibrillation (AF), the most common cardiac arrhythmia in the general population, has significant healthcare burden. Little is known about AF in octogenarians.

OBJECTIVE

To describe the prevalence and incidence rate of AF in New Zealand (NZ) octogenarians and the risk of stroke and mortality at 5-year follow-up.

DESIGN

Longitudinal Cohort Study.

SETTING

Bay of Plenty and Lakes health regions of New Zealand.

SUBJECTS

Eight-hundred-seventy-seven (379 indigenous Māori, 498 non-Māori) were included in the analysis.

METHODS

AF, stroke/TIA events and relevant co-variates were established annually using self-report and hospital records (and ECG for AF). Cox proportional-hazards regression models were used to determine the time dependent AF risk of stroke/TIA.

RESULTS

AF was present in 21% at baseline (Māori 26%, non-Māori 18%), the prevalence doubled over 5-years (Māori 50%, non-Māori 33%). 5-year AF incidence was 82.6 /1000-person years and at all times AF incidence for Māori was twice that of non-Māori. Five-year stroke/TIA prevalence was 23% (22% in Māori and 24% non- Māori), higher in those with AF than without. AF was not independently associated with 5-year new stroke/TIA; baseline systolic blood pressure was. Mortality was higher for Māori, men, those with AF and CHF and statin use was protective. In summary, AF is more prevalent in indigenous octogenarians and should have an increased focus in health care management. Further research could examine treatment in more detail to facilitate ethnic specific impact and risks and benefits of treating AF in octogenarians.

Cardiovascular Risk Factor Control in 70- to 95-Year-Old Individuals: Cross-Sectional Results from the Population-Based AugUR Study

Cardiovascular risk factors such as high glucose, LDL-cholesterol, blood pressure, and impaired kidney function are particularly frequent in old-aged individuals. However, population-based data on the extent of cardiovascular risk factor control in the old-aged population is limited. AugUR is a cohort of the mobile “70+”-year-old population of/near Regensburg, recruited via population registries. We conducted cross-sectional analyses assessing the proportion of AugUR participants with LDL-cholesterol, HbA1c, or blood pressure beyond recommended levels and their association with impaired creatinine- and cystatin-based estimated glomerular filtration rate (eGFR, <60 mL/min/1.73 m2) or urine albumin–creatinine ratio (UACR, ≥30 mg/g). Among 2215 AugUR participants, 74.7% were taking lipid-, glucose-, blood-pressure-lowering, or diuretic medication. High LDL-cholesterol at ≥116 mg/dL was observed for 76.1% (51.1% among those with prior cardiovascular events). We found HbA1c ≥ 7.0% for 6.3%, and high or low systolic blood pressure for 6.8% or 26.5%, respectively (≥160, <120 mmHg). Logistic regression revealed (i) high HbA1c levels associated with increased risk for impaired kidney function among those untreated, (ii) high blood pressure with increased UACR, and (iii) low blood pressure with impaired eGFR, which was confined to individuals taking diuretics. Our results provide important insights into cardiovascular risk factor control in individuals aged 70–95 years, which are understudied in most population-based studies.

[Prescriptions of statins in the elderly according to the type of healthcare establishment: An example of the usefulness of territorial hospital groups]

INTRODUCTION

The challenge of territorial hospital groups is to develop coherent care pathways for optimal patient care. Following the creation of a territorial pharmaceutical team, a common prescription review process was initiated in our health area. The objective of this study is to analyze the uses of statins in the elderly.

METHOD

The study included all statin-treated patients older than 75 years at the five participating institutions (including long-term nursing homes). In a prospective multicenter study, the benefit/risk ratio of statin prescription has been assessed up. Depending on the clinical situation, a proposal to stop or adjust the dosage could be made.

RESULTS

Nine hundred and forty-seven patients were included. Among them, 184 were treated with a statin. Forty-seven patients (26%) are treated in primary prevention and 137 patients (74%) in secondary prevention. Dosages are lower for long stays. Fifteen treatments interruption were accepted out of 44 proposals, mostly for long stays. The reasons given to continue treatment are the need for a new evaluation by a cardiologist or a high cardiovascular risk.

CONCLUSION

The variability of results according to the type healthcare institution makes territorial medical and pharmaceutical collaboration relevant. The challenge is to develop a coherent care pathway for optimal care of elderly patients, with congruent objectives.

Body mass index trajectories and mortality in community-dwelling older adults: population-based cohort study

OBJECTIVE

Both low and high body mass index (BMI) have been associated with greater mortality in older adults. This study aimed to evaluate the trajectory of BMI in the final years of life.

METHODS

A population-based cohort study was conducted including community-dwelling adults in the English Longitudinal Study of Ageing between 1998 and 2012. BMI was evaluated in relation to age and years before death. Number of long-term conditions, cigarette smoking and socioeconomic position were evaluated as effect modifiers.

RESULTS

Data were analysed for 16 924 participants with 31 857 BMI records; mean age at study starts, 61.6 (SD 10.9) years; mean BMI, 27.5 (4.7) Kg/m². There were 3686 participants (4794 BMI records) who died and 13 238 participants (27 063 BMI records) who were alive at last follow-up. Mean BMI increased with age to 60-69 years but then declined, but the age-related decline was more rapid in decedents. From 4 to 7 years before death or end of study, adjusted mean BMI was 0.87 (95% CI 0.50 to 1.24) Kg/m² lower for male decedents than survivors and 1.02 (0.56 to 1.47) lower in women; and from 3 to 0 years before death, BMI was 1.39 (0.98 to 1.80) Kg/m² lower in male decedents and 2.12 (1.60 to 2.64) lower in female decedents. Multiple long-term conditions and lower socioeconomic position were associated with higher peak BMI and greater BMI decline; current smoking was associated with lower BMI and greater BMI decline.

CONCLUSIONS

In community-dwelling older adults, mean BMI enters an accelerating decline from up to 8 years before death. Multiple long-term conditions, smoking and lower socioeconomic position are associated with BMI decline.

Improving individualized prescription in patients with multimorbidity through medication review

Background

Older patients tend to have multimorbidity, represented by multiple chronic diseases or geriatric conditions, which leads to a growing number of prescribed medications. As a result, pharmacological prescription has become a major concern because of the increased difficulties to ensure appropriate prescription in older adults. The study’s main objectives were to characterize a cohort of older adults with multimorbidity, carry out a medication review and compare the pharmacological data before and after the medication review globally and according to the frailty index.

Methods

This was a quasi-experimental (uncontrolled pre-post) study with a cohort of patients ≥ 65 years old with multimorbidity. Data were collected from June 2019 to October 2020. Variables assessed included demographic, clinical, and pharmacological data, degree of frailty (Frail-VIG index), medication regimen complexity index, anticholinergic and or sedative burden index, and monthly drug expenditure. Finally, a medication review was carried out by an interdisciplinary team (primary care team and a consultant team with a geriatrician and a clinical pharmacist) by applying the Patient-Centered Prescription model to align the treatment with care goals.

Results

Four hundred twenty-eight patients were recruited [66.6% women; mean age 85.5 (SD 7.67)]. The mean frail index was 0.39 (SD 0.13), corresponding with moderate frailty. Up to 90% of patients presented at least one inappropriate prescription, and the mean of inappropriate prescriptions per patient was 3.14 (SD 2.27). At the three-month follow-up [mortality of 17.7% (n = 76)], the mean chronic medications per patient decreased by 17.96%, varying from 8.13 (SD 3.87) to 6.67 (SD 3.72) (p < 0.001). The medication regimen complexity index decreased by 19.03%, from 31.0 (SD 16.2) to 25.1 (SD 15.1), and the drug burden index mean decreased by 8.40%, from 1.19 (SD 0.82) to 1.09 (SD 0.82) (p < 0.001). A decrease in polypharmacy, medication regimen complexity index, and drug burden index was more frequent among frail patients, especially those with severe frailty (p < 0.001).

Conclusions

An individualized medication review in frail older patients, applying the Patient-Centered Prescription model, decreases pharmacological parameters related to adverse drug effects, such as polypharmacy, therapeutical complexity, and anticholinergic and, or sedative burden. The benefits are for patients with frailty.

The association of apolipoproteins with later-life all-cause and cardiovascular mortality: a population-based study stratified by age

Midlife lipid levels are important predictors of cardiovascular diseases, yet their association with mortality in older adults is less clear. We aimed to (1) identify lipid profiles based on cholesterol, triglycerides, and apolipoproteins using cluster analysis, and (2) investigate how lipid profiles and lipid levels at different ages are associated with later-life all-cause and cardiovascular mortality. We used data from 98,270 individuals in the Swedish AMORIS cohort who had blood measurements between 1985-1996 and were followed until 2012. Over the follow-up (mean 18.0 years), 30,730 (31.3%) individuals died. Three lipid profiles were identified. Compared with reference profile, a high lipid profile (low ApoA-I and high total cholesterol (TC), triglycerides, ApoB, and ApoB/ApoA-I ratio) at ages 39-59 or 60-79 was associated with higher all-cause mortality. A high lipid profile at ≥ 80 years, however, did not confer higher mortality. For the specific markers, high TC (≥ 7.25 mmol/L) was associated with higher all-cause mortality in ages 39-59 but lower mortality in ages 60-79 and ≥ 80. Low ApoA-I (< 1.28 g/L) and high ApoB/ApoA-I ratio (≥ 1.18), on the other hand, were associated with higher cardiovascular mortality regardless of age at lipid measurement, highlighting their potential relevance for survival in both young and older individuals.

Therapeutic optimization through goal-oriented prescription in nursing homes

Background People living in nursing homes are highly vulnerable and frail. Polypharmacy and inappropriate prescription (IP) are also common problems. Objectives The objectives of the study are (i) to study the baseline situation and calculate the frailty index (FI) of the residents, (ii) to assess the results of routine clinical practice to do a pharmacotherapy review (patient-centred prescription (PCP) model) (Molist Brunet et al., Eur Geriatr Med. 2015;6:565-9) and (iii) to study the relationship between IP and frailty, functional dependence, advanced dementia and end-of-life situation. Setting Two nursing homes in the same geographical area in Catalonia (Spain). Method This was a prospective, descriptive and observational study of elderly nursing home residents. Each patient's treatment was analysed by applying the PCP model, which centres therapeutic decisions on the patient's global assessment and individual therapeutic goal. Main outcome measure Prevalence of polypharmacy and IP. Results 103 patients were included. They were characterized by high multimorbidity and frailty. Up to 59.2% were totally dependent. At least one IP was identified in 92.2% of residents. Prior to the pharmacological review, the mean number of chronic medications prescribed per resident was 6.63 (SD 2.93) and after this review it was 4.97 (SD 2.88). Polypharmacy decreased from 72.55% to 52.94% and excessive polypharmacy fell from 18.62% to 5.88%.The highest prevalence of IP was detected in people with a higher FI, in those identified as end-of-life, and also in more highly dependent residents (p < 0.05). Conclusions People who live in nursing homes have an advanced frailty. Establishing individualized therapeutic objectives with the application of the PCP model enabled to detect 92.2% of IP. People who are frailer, are functionally more dependent and those who are end-of-life are prescribed with inappropriate medication more frequently.

Perspective: The Saturated Fat-Unsaturated Oil Dilemma: Relations of Dietary Fatty Acids and Serum Cholesterol, Atherosclerosis, Inflammation, Cancer, and All-Cause Mortality

PUFAs are known to regulate cholesterol synthesis and cellular uptake by multiple mechanisms that do not involve SFAs. Polymorphisms in any of the numerous proteins involved in cholesterol homeostasis, as a result of genetic variation, could lead to higher or lower serum cholesterol. PUFAs are susceptible to lipid peroxidation, which can lead to oxidative stress, inflammation, atherosclerosis, cancer, and disorders associated with inflammation, such as insulin resistance, arthritis, and numerous inflammatory syndromes. Eicosanoids from arachidonic acid are among the most powerful mediators that initiate an immune response, and a wide range of PUFA metabolites regulate numerous physiological processes. There is a misconception that dietary SFAs can cause inflammation, although endogenous palmitic acid is converted to ceramides and other cell constituents involved in an inflammatory response after it is initiated by lipid mediators derived from PUFAs. This article will discuss the many misconceptions regarding how dietary lipids regulate serum cholesterol, the fact that all-cause death rate is higher in humans with low compared with normal or moderately elevated serum total cholesterol, the numerous adverse effects of increasing dietary PUFAs or carbohydrate relative to SFAs, as well as metabolic conversion of PUFAs to SFAs and MUFAs as a protective mechanism. Consequently, dietary saturated fats seem to be less harmful than the proposed alternatives.

Value of total cholesterol readings earlier versus later in life to predict cardiovascular risk

BACKGROUND

Prognostic implications of blood cholesterol may differ at different stages of life. This cohort study compares the value of total cholesterol (TC) readings earlier versus later in life for the prediction of coronary atherosclerosis, cardiovascular events, and cardiovascular death.

METHODS

In a cardiovascular observation study (CVOS) we performed coronary angiography and prospectively recorded cardiovascular events in 1090 patients over up to 19 years. These patients had participated in a health survey (HS) 15 years prior to the CVOS baseline. TC was measured twice, first at the earlier HS and then later at CVOS recruiting.

FINDINGS

Patients in the highest versus the lowest TC-category of the HS had an OR of 4.30 [2.41-7.65] for significant CAD at angiography, a HR of 1.74 [1.10-2.76] for cardiovascular events, and a HR of 7.55 [1.05-54.49] for cardiovascular death after multivariate adjustment. In contrast, TC as measured at the baseline of the CVOS was neither significantly associated with significant CAD (OR= 0.75 [0.49-1.13]) nor with cardiovascular events or death during follow-up (HR= 0.86 [0.62-1.18] and 0.79 [0.41-1.53], respectively). Moreover, the ESC/EAS-SCORE was found to be more powerful in predicting cardiovascular mortality when using earlier instead of later TC, with a continuous net reclassification improvement of 0.301 (p<0.001).

INTERPRETATION

Early measurement not only enables early intervention in keeping with the concept of lifelong exposure to atherogenic lipoproteins. These data also suggest that cardiovascular risk prediction is more accurate if using earlier in life TC readings.

FUNDING

The present study did not receive any particular funding.

A nonlinear association of total cholesterol with all-cause and cause-specific mortality

Background

The link between total cholesterol (TC) and all-cause and specific mortality has not been elucidated. Herein, we aimed to evaluate the effect of TC levels on all-cause, cardiovascular disease (CVD), and cancer mortality.

Methods

All data analyzed were obtained from the National Health and Nutrition Examination Survey 1999–2014. The relationship between levels of TC and mortality was determined through Cox proportional hazard regression analysis coupled with multivariable adjustments. Two-piecewise linear regression models and Cox models with penalized splines were applied to explore nonlinear and irregular shape relationships. Kaplan–Meier survival curve and subgroup analyses were conducted.

Results

The sample studied comprised 14,662 men and 16,025 women, categorized as 25,429 adults aged 18–65 and 5,258 adults over 65 years old. A total of 2,570 deaths were recorded. All-cause, cardiovascular, and cancer mortality showed U-curve associations after adjusting for confounding variables in the restricted cubic spline analysis. Hazard ratios (HRs) of all-cause and cancer mortality were particularly negatively related to TC levels in the lower range < 200 mg/dL, especially in the range < 120 mg/dL (HR 1.97; 95% CI 1.38, 2.83, HR 2.39; 95% CI 1.21, 4.71, respectively). However, the HRs of cardiovascular disease mortality in the range < 120 mg/dL were the lowest (HR 0.60; 95% CI 0.15, 2.42). In the upper range, a TC range of ≥ 280 mg/dL was correlated with mortality as a result of CVD and cancer (HR 1.31; 95% CI 0.87, 1.97 and HR 1.22; 95% CI 0.82, 1.79). The lowest cumulative survival rate of all-cause mortality was recorded in the lowest TC-level group, while the lowest cumulative survival rate of CVD mortality was recorded in the highest TC-level group.

Conclusions

A nonlinear association of TC level with all-cause, cancer, and CVD mortality in the American population was observed, suggesting that too low or too high serum total cholesterol levels might correlate with adverse outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12986-021-00548-1.

Association between low density lipoprotein and all cause and cause specific mortality in Denmark: prospective cohort study

OBJECTIVE

To determine the association between levels of low density lipoprotein cholesterol (LDL-C) and all cause mortality, and the concentration of LDL-C associated with the lowest risk of all cause mortality in the general population.

DESIGN

Prospective cohort study.

SETTING

Denmark; the Copenhagen General Population Study recruited in 2003-15 with a median follow-up of 9.4 years.

PARTICIPANTS

Individuals randomly selected from the national Danish Civil Registration System.

MAIN OUTCOME MEASURES

Baseline levels of LDL-C associated with risk of mortality were evaluated on a continuous scale (restricted cubic splines) and by a priori defined centile categories with Cox proportional hazards regression models. Main outcome was all cause mortality. Secondary outcomes were cause specific mortality (cardiovascular, cancer, and other mortality).

RESULTS

Among 108 243 individuals aged 20-100, 11 376 (10.5%) died during the study, at a median age of 81. The association between levels of LDL-C and the risk of all cause mortality was U shaped, with low and high levels associated with an increased risk of all cause mortality. Compared with individuals with concentrations of LDL-C of 3.4-3.9 mmol/L (132-154 mg/dL; 61st-80th centiles), the multivariable adjusted hazard ratio for all cause mortality was 1.25 (95% confidence interval 1.15 to 1.36) for individuals with LDL-C concentrations of less than 1.8 mmol/L (<70 mg/dL; 1st-5th centiles) and 1.15 (1.05 to 1.27) for LDL-C concentrations of more than 4.8 mmol/L (>189 mg/dL; 96th-100th centiles). The concentration of LDL-C associated with the lowest risk of all cause mortality was 3.6 mmol/L (140 mg/dL) in the overall population and in individuals not receiving lipid lowering treatment, compared with 2.3 mmol/L (89 mg/dL) in individuals receiving lipid lowering treatment. Similar results were seen in men and women, across age groups, and for cancer and other mortality, but not for cardiovascular mortality. Any increase in LDL-C levels was associated with an increased risk of myocardial infarction.

CONCLUSIONS

In the general population, low and high levels of LDL-C were associated with an increased risk of all cause mortality, and the lowest risk of all cause mortality was found at an LDL-C concentration of 3.6 mmol/L (140 mg/dL).

Functional principal component based landmark analysis for the effects of longitudinal cholesterol profiles on the risk of coronary heart disease

Patients' longitudinal biomarker changing patterns are crucial factors for their disease progression. In this research, we apply functional principal component analysis techniques to extract these changing patterns and use them as predictors in landmark models for dynamic prediction. The time-varying effects of risk factors along a sequence of landmark times are smoothed by a supermodel to borrow information from neighbor time intervals. This results in more stable estimation and more clear demonstration of the time-varying effects. Compared with the traditional landmark analysis, simulation studies show our proposed approach results in lower prediction error rates and higher area under receiver operating characteristic curve (AUC) values, which indicate better ability to discriminate between subjects with different risk levels. We apply our method to data from the Framingham Heart Study, using longitudinal total cholesterol (TC) levels to predict future coronary heart disease (CHD) risk profiles. Our approach not only obtains the overall trend of biomarker-related risk profiles, but also reveals different risk patterns that are not available from the traditional landmark analyses. Our results show that high cholesterol levels during young ages are more harmful than those in old ages. This demonstrates the importance of analyzing the age-dependent effects of TC on CHD risk.

Use of prescription medication in the last years of life: a population-based comparison of two oldest old Danish birth cohorts born 10 years apart

INTRODUCTION

Age limits for diagnostics and treatments have been largely removed and replaced by an active diagnostic and treatment practice among the oldest old and has led to concerns about potential overtreatment during the last years of life.

METHODS

Use of prescription medication in the last years of life was assessed from 1995 to 2012 for the entire 1905 and 1915 Danish birth cohorts using nationwide register data. Medication use was quantified as the number different pharmacy-redeemed drugs during 120 days up to a given date.

RESULTS

For both cohorts, prescription medication use increased with proximity to death and calendar year, while age at death had little impact; use in the 1915 cohort was markedly higher than in the 1905 cohort. Average number of prescription medications varied from below 3 to above 9 depending on age, calendar year and proximity to death. From 1995 to 2005, average number of prescription medications for a 90-year-old person in the last month of life increased from 6.0 to 8.7. Out of 90-year-old persons dying in 2005, 82% were exposed to polypharmacy, up from 63% in 1995.

CONCLUSIONS

Prescription medication use accelerates throughout the last of years life among two Danish oldest old cohorts born 10 years apart, with substantially larger use in the most recent cohort. This pattern suggests an increase in drug prescribing regimens in the period 1995-2012, reinforcing the need for evidence-based guidelines on medications in the particularly vulnerable population of the oldest old patients in their last years of life.

Cardiovascular effect of discontinuing statins for primary prevention at the age of 75 years: a nationwide population-based cohort study in France

Aims

The role of statin therapy in primary prevention of cardiovascular disease in persons older than 75 years remains a subject of debate with little evidence to support or exclude the benefit of this treatment. We assessed the effect of statin discontinuation on cardiovascular outcomes in previously adherent 75-year-olds treated for primary prevention.

Methods and results

A population-based cohort study using French national healthcare databases was performed, studying all subjects who turned 75 in 2012–14, with no history of cardiovascular disease and with a statin medication possession ratio ≥80% in each of the previous 2 years. Statin discontinuation was defined as three consecutive months without exposure. The outcome was hospital admission for cardiovascular event. The hazard ratio comparing statin discontinuation with continuation was estimated using a marginal structural model adjusting for both baseline and time-varying covariates (cardiovascular drug use, comorbidities, and frailty indicators). A total of 120 173 subjects were followed for an average of 2.4 years, of whom 17 204 (14.3%) discontinued statins and 5396 (4.5%) were admitted for a cardiovascular event. The adjusted hazard ratios for statin discontinuation were 1.33 [95% confidence interval (CI) 1.18–1.50] (any cardiovascular event), 1.46 (95% CI 1.21–1.75) (coronary event), 1.26 (95% CI 1.05–1.51) (cerebrovascular event), and 1.02 (95% CI 0.74–1.40) (other vascular event).

Conclusion

Statin discontinuation was associated with a 33% increased risk of admission for cardiovascular event in 75-year-old primary prevention patients. Future studies, including randomized studies, are needed to confirm these findings and support updating and clarification of guidelines on the use of statins for primary prevention in the elderly.

High-Sensitivity Cardiac Troponin I Improves Cardiovascular Risk Prediction in Older Men: HIMS (The Health in Men Study)

Background

The Framingham Risk Score estimates the 10‐year risk of cardiovascular events. However, it performs poorly in older adults. We evaluated the incremental benefit of adding high‐sensitivity cardiac troponin I (hs‐cTnI) to the Framingham Risk Score.

Methods and Results

The HIMS (Health in Men Study) is a cohort study of community‐dwelling men aged 70 to 89 years in Western Australia. Participants were identified from the electoral roll, with a subset undergoing plasma analysis. Hs‐cTnI (Abbott Architect i2000SR) was measured in 1151 men without prior cardiovascular disease. The Western Australia Data Linkage System was used to identify incident cardiovascular events. After 10 years of follow‐up, 252 men (22%) had a cardiovascular event (CVE+) and 899 did not (CVE–). The Framingham Risk Score placed 148 (59%) CVE+ and 415 (46%) CVE– in the high‐risk category. In CVE– men, adding hs‐cTnI affected the risk categories of 244 (27.2%) men, with 64.8% appropriately reclassified to a lower and 35.2% to a higher category, which decreased the number of high‐risk men in the CVE– to 39%. In CVE+ men, adding hs‐cTnI affected the risk categories of 61 (24.2%), with 50.8% appropriately reclassified to a higher and 49.2% to a lower category and 82.5% remaining above the 15% risk treatment threshold. The net reclassification index was 0.305 (P<0.001). Adding hs‐cTnI increased the C‐statistic modestly from 0.588 (95% CI, 0.552–0.624) to 0.624 (95% CI, 0.589–0.659) and improved model fit (likelihood ratio test, P<0.001).

Conclusions

Adding hs‐cTnI to the Framingham Risk Score provided incremental prognostic benefit in older men, especially aiding reclassification of individuals into a lower risk category.

The long-term effectiveness of metabolic control on cardiovascular disease in patients with diabetes in a real-world health care setting - A prospective diabetes management study

AIMS

To determine the incidence rates of cardiovascular disease (CVD) and assess the effect of metabolic risk factor management on the development of CVD in patients with diabetes.

METHODS

We studied 733 patients with diabetes without prior CVD in the Shanghai Taopu community health service center. Success in managing CVD risk factors was evaluated as follows: (1) glucose control (haemoglobin A1c [HbA1c] <7.0% in patients aged <65years and <8.0% in patients aged ≥65years), (2) blood pressure control (<140/90mmHg), and (3) lipid control (high-density lipoprotein cholesterol ≥1.0mmol/L in men and ≥1.3mmol/L in women, and triglycerides <1.7mmol/L).

RESULTS

During a median 8.0-year follow-up, 206 CVD incident cases were identified. Each 1% increment in HbA1c, 10mmHg increment in systolic blood pressure (SBP), and 1mmol/L increment in triglycerides during follow-up significantly increased the risk of CVD by 17%, 37%, and 14%, respectively. Compared to those who did not, patients who met the blood pressure and glucose control goals during follow-up had a 64% and a 29% decreased risk of CVD, respectively. The multivariable-adjusted hazard ratios of CVD were 1.00, 1.78 (95% confidence interval [CI] 1.10-2.87), and 2.51 (95% CI 1.54-4.07) among patients who attained three, two, and one/none of the CVD factor control goals (HbA1c, blood pressure, and lipid) during follow-up, respectively.

CONCLUSIONS

Average levels of HbA1c, SBP, and triglycerides during follow-up were positively associated with the risk of CVD, and treatment targeting multiple factors can significantly reduce CVD risk.

Discontinuing statins or not in the elderly? Study protocol for a randomized controlled trial

Background

The risk/benefit ratio of using statins for primary prevention of cardiovascular (CV) events in elderly people has not been established. The main objectives of the present study are to assess the cost-effectiveness of statin cessation and to examine the non-inferiority of statin cessation in terms of mortality in patients aged 75 years and over, treated with statins for primary prevention of CV events.

Methods

The “Statins in the elderly” (SITE) study is an ongoing 3-year follow-up, open-label comparative multi-centre, randomized clinical trial that is being conducted in two parallel groups in outpatient primary care offices. Participants meeting the following criteria are included: people aged 75 years and older being treated with statins as primary prevention for CV events, who provide informed consent. After randomization, patients in the statin-cessation strategy are instructed to withdraw their treatment. In the comparison strategy, patients continue their statin treatment at the usual dosage. The cost-effectiveness of the statin-cessation strategy compared to continuing statins will be estimated through the incremental cost per quality-adjusted life years (QALYs) gained at 36 months, from the perspective of the French healthcare system. Overall mortality will be the primary clinical endpoint. We assumed that the mortality rate at 3 years will be 15%. The sample size was computed to achieve 90% power in showing the non-inferiority of statin cessation, assuming a non-inferiority margin of 5% of the between-group difference in overall mortality. In total, the SITE study will include 2430 individuals.

Discussion

There is some debate on the value of statins in people over 75 years old, especially for primary prevention of CV events, due to a lack of evidence of their efficacy in this population, potential compliance-related events, drug-drug interactions and side effects that could impair quality of life. Data from clinical trials guide the initiation of medication therapy for primary or secondary prevention of CV disease but do not define the timing, safety, or risks of discontinuing the agents. The SITE study is one of the first to examine whether treatment cessation is a cost-effective and a safe strategy in people of 75 years and over, formerly treated with statins.

Trial registration

ClinicalTrials.gov: NCT02547883. Registered on 11 September 2015.

Renal Evaluation and Protection

Diabetes and diabetic nephropathy have become more prevalent in the elderly population. Diabetic nephropathy has become increasingly prevalent in the elderly population. The presence of this disease in an age group suffering multiple comorbidities has altered the pathophysiology and leading cause of mortality. Mortality has become linked more often to cardiovascular events rather than progression of end-stage-renal-disease, which explains the recent shift of focus of trials to improving cardiovascular-outcomes in patients with diabetes. In this chapter, we emphasize the difference in treatment modalities and goals of therapy in elderly versus young. In addition, we discuss results from recent outcome trials with regards to renal benefits of sodium-glucose co-transporter-2-inhibitors and glucagon-like peptide-1-receptor-agonists.

Potential Statin Overuse in Older Patients: A Retrospective Cross-Sectional Study Using French Health Insurance Databases

BACKGROUND

Although compelling evidence exists supporting statins (HMG-CoA reductase inhibitors) for secondary prevention in older patients with clinical atherosclerotic diseases, the same cannot be said for primary prevention.

OBJECTIVES

The objectives of this study were to estimate the frequency of potential statin overuse in older patients, the potential drug cost savings if corrected, and the associated factors.

METHODS

A retrospective cross-sectional study was conducted in Alsace and Lorraine (France) from 1 January to 30 April 2017. All statin users aged 80 years or over living in the community (including nursing homes) and identified from the French health insurance database were analyzed. Potential statin overuse was defined according to the STOPP/START (Screening Tool of Older People's Prescriptions/Screening Tool to Alert to Right Treatment) criteria.

RESULTS

Among the 38,268 aged insured, 23,228 (60.7%) had potential statin overuse. Of those living in the community, 22,132 (60.0%) patients had potential statin overuse: 12,352 (55.8%) for primary and 9780 (44.2%) for secondary prevention. Among nursing home residents, 1096 (79.0%) had potential statin overuse: 394 (35.9%) for primary and 702 (64.1%) for secondary prevention. The potential drug cost savings associated with the adjustment of potential statin overuse were €924,100 for the study period. Living in nursing home [adjusted odds ratio (OR_adjusted) 3.91, 95% confidence interval (CI) 2.82-5.41] and being a female (OR_adjusted 2.84, 95% CI 2.54-3.17) were the main risk factors associated with potential statin overuse.

CONCLUSION

The frequency of potential statin overuse is very high among older people aged 80 years or over, highlighting the need to re-evaluate statin therapy and consider deprescribing, particularly for primary prevention and in nursing homes.

Outcomes and Predictors of Mortality in Hospitalized Frail Patients Undergoing Percutaneous Coronary Intervention

Objective To study the impact of frailty on inpatient outcomes among patients undergoing percutaneous coronary intervention (PCI). Methods The National Inpatient Sample data of all PCI-related hospitalizations throughout the United States (US) from 2010 through 2014 was utilized. Patients were divided into two groups: frailty and no-frailty. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes were used to stratify groups and outcomes. In order to address the substantial difference in the total number of valid observations between the two groups, a propensity-matched analysis was performed at a 1:1 ratio and caliper width of 0.01. Results A total of 2,612,661 PCI-related hospitalizations throughout the US from 2010 through 2014 were identified, out of which 16,517 admissions (0.6%) had coexisting frailty. Only 1:1 propensity-matched data was utilized for the study. Propensity-matched frailty group (n=14,717) as compared to no-frailty (n=14,755) was frequently older, white, and Medicare enrollee (p<0.05). The frailty group had significantly higher rates of comorbidities and complications (p<0.05). All-cause in-hospital mortality was higher in the no-frailty group (p<0.05). Age, white race, non-elective admission, urban hospitals, and comorbidities predicted in-hospital mortality in frailty group (p<0.05). Rheumatoid arthritis, depression, hypertension, obesity, dyslipidemia, and history of previous PCI decreased odds of in-hospital mortality in frailty group (p<0.05). Frailty group had prolonged hospital stay and higher hospital charges (p<0.05). Conclusions Frailty has a significant effect on PCI-related outcomes. We present a previously unknown protective effect of cardiovascular disease risk factors and other health risk factors on frail patients undergoing PCI. Frailty's inclusion in risk stratification will help in predicting the post-procedure complications and improve resource utilization.

Real-Life Benefits of Statins for Cardiovascular Prevention in Elderly Subjects: A Population-Based Cohort Study

OBJECTIVES

The benefits of initiating statins in the elderly remains debated. We evaluated the effects of initiating statins in the elderly, according to cardiovascular risk.

METHODS

This population-based cohort study used data of the representative sample of the French health care system database for the 2008-2015 period. New users of statins, aged 75 years and older, were dynamically included in the cohort and matched 1:1 to statin nonusers on age, sex, numbers of different drugs dispensed and medical consultations, and cardiovascular history. Patients were classified into 3 cardiovascular risk groups: secondary prevention (history of coronary heart disease), primary prevention with modifiable risk factors (diabetes or cardiovascular medications), and primary prevention without modifiable risk factors (none of the above). Effect of cumulative use of statins on occurrence of acute coronary syndrome or all-cause death was analyzed by using multivariable time-dependent Cox models stratified on cardiovascular risk at inclusion.

RESULTS

Among the 7284 patients included, median follow-up was 4.7 years. Cumulative use of statins was associated with a lower risk of outcomes in the primary prevention with modifiable risk factors group (adjusted hazard ratio 0.93 per year of use; 95% confidence interval, 0.89-0.96; P < .01) and in the secondary prevention group (0.75; 0.63-0.90; P < .01), but not in the primary prevention without modifiable risk factors group (1.01; 0.86-1.18; P = .92).

CONCLUSIONS

Statin treatment was not associated with a reduction in acute coronary syndrome or all-cause death in elderly without modifiable cardiovascular risk factor treated in primary prevention.

Comparison of Patients with Acute Myocardial Infarction According to Age

Introduction

By development of the medicine, control of the risk factors for acute myocardial infarction (AMI), became the foundation of cardiology.

Aim

To investigate the association of the age with presence of risk factors in patients with acute myocardial infarction.

Methods

The study had a prospective, comparative and descriptive character, and it was done on a sample of 80 patients (n=80; 55 male and 25 female) Clinic for Heart, Blood Vessel and Rheumatic Diseases, Clinical Center University of Sarajevo from January 2016 to August 2018. All patients were hospitalized under the diagnosis of myocardial infarction and were divided into two main groups, which were divided into two subgroups according to age. Group A, group of patients under 45 years of age at the moment of diagnosis of AMI (n = 40; men = 29; women = 11) was divided into group A1 (n = 20; patients aged 25-35 years) and group A2 (n = 20; patients aged between 35-45 years). Group B, patients older than 45 years at the time of diagnosis of AMI (n = 40; men = 26, women = 14) was divided into group B1 (n = 20; patients aged between 45-55 years) and group B2 (n = 20; patients aged 55-65 years of age).

Results

According to gender distribution, there is a significantly higher incidence of hypertension in male patients aged 25-35 years and between 35-45 years (p = 0.01; p = 0.01). Increased cholesterol values were significantly more common in men aged 25-35 years (p = 0.0121). Increased triglyceride values were significantly more common in men aged 25-35 years, in comparison to female respondents of the same age (86.67% vs. 13.33%, p = 0.0001). There was a significant significance between the two groups in the occurrence of anteroseptal (p = 0.04) and in the diaphragmatic myocardial infarction (p = 0.01), while in other infarction localities no significant significance was observed.

Conclusion

Male sex is a predisposing risk factor for the development of a cardiovascular incident in the younger age. The post infarction ejection fraction of the left ventricle was significantly reduced in younger patients. The potential for prevention should be of paramount importance. The localization of the incident itself, and the involvement of a certain blood, represents, regardless of all the research, still a fact that is hard to stratify and directly correlated with a certain risk factor.

Statins for primary prevention of cardiovascular disease: modelling guidelines and patient preferences based on an Irish cohort

BACKGROUND

Changes in clinical guidelines for primary prevention of cardiovascular disease (CVD) have widened eligibility for statin therapy.

AIM

To illustrate the potential impacts of changes in clinical guidelines.

DESIGN AND SETTING

Modelling the impacts of seven consecutive European guidelines based on a cohort of people aged ≥50 years from the Irish Longitudinal Study on Ageing.

METHOD

The eligibility for statin therapy of a sample of people without a history of CVD was established, according to changing guideline recommendations and modelled associated potential costs. The authors calculated the numbers needed to treat (NNT) to prevent one major vascular event in patients at the lowest baseline risk for which each of the seven guidelines recommended treatment, and for those at low, medium, high, and very-high risk according to 2016 guidelines. These were compared with the NNT that patients reported as required to justify taking a daily medicine.

RESULTS

The proportion of patients eligible for statins increased from approximately 8% in 1987 to 61% in 2016; associated costs rose from €13.9 million to €107.1 million per annum. The NNT for those at the lowest risk for which each guideline recommended treatment rose from 40 to 400. By 2016, the NNT for low-risk patients was 400 compared to ≤25 very-high risk patients. The proportion of patients eligible for statins achieving NNT levels that patients regarded as justified to taking a daily medicine fell as guidelines changed over time.

CONCLUSION

Increased eligibility for statin therapy impacts large proportions of the present population and healthcare budgets. Decisions to take and reimburse statins should be considered on the basis of expected cost-effectiveness and acceptability to patients.

Differences in preventing new-onset cardiovascular events with statin therapy in seniors aged 75 years and over: A cohort study in the South Korean National Health Insurance Database

The aim of this cohort study was to compare the effectiveness of statin regimens for primary prevention among seniors aged ≥ 75 years. Seniors aged 75-100 years for whom statin therapies for primary prevention were newly initiated between 1 January 2009 and 31 December 2011, and who continued the same statin regimen during the first year after the index date were identified using the claims data from the South Korean National Health Insurance Database. A propensity score matching and multivariable Cox proportional hazards model were developed to evaluate adjusted ischaemic cardiovascular-cerebrovascular event (CCE) risk and all-cause mortality risk for all patients, as well as for subgroups. A total of 5629 older patients aged 75-100 years were included in the study population. Compared to moderate-intensity statin therapy, low-intensity statin therapy was significantly associated with increased risk of ischaemic CCEs, while high-intensity statin therapy was associated with reduced risk of ischaemic CCEs; however, compared to moderate-intensity statin therapy, both low-intensity and high-intensity statin therapies were associated with increased risk of all-cause mortality. For the 4689 older patients who regularly received moderate-intensity statin therapy including 10 mg atorvastatin, 20 mg atorvastatin, 10 mg rosuvastatin or 20 mg simvastatin for primary prevention, multivariable regression adjusting for potential covariates revealed no significant difference in ischaemic CCEs or all-cause mortality between the moderate-intensity statin users and 10 mg atorvastatin users both before and after propensity scoring matching. No significant heterogeneity was detected in the patient subgroups. The results of this study based on real-world data can supply evidence-based reasons for choice of statin regimen for the primary prevention of CCEs in older people aged ≥ 75 years.

Statin and clinical outcomes of primary prevention in individuals aged >75 years: The SCOPE-75 study

BACKGROUND AND AIMS

Limited data is available on the benefit of statin for primary prevention in the elderly. The aim of this study is to investigate whether statin for primary prevention is effective in lowering the cardiovascular risk and all-cause death in individuals aged >75 years.

METHODS

This was a retrospective, propensity score-matched study and data were acquired between 2005 and 2016 in a tertiary university hospital. Of the 6414 patients screened, 1559 statin-naïve patients without a history of atherosclerotic cardiovascular disease before the index visit were included. After propensity score matching, 1278 patients (639 statin users, 639 statin non-users) were finally analyzed. Primary outcome variables included major adverse cardiovascular and cerebrovascular events (MACCE) and all-cause death. MACCE included cardiovascular death, nonfatal myocardial infarction, coronary revascularization, and nonfatal stroke or transient ischemic attack.

RESULTS

At a median follow-up of 5.2 years, statin users had lower rates of MACCE (2.15 vs. 1.25 events/100 person-years; hazard ratio, 0.59; p = 0.005) and all-cause death (1.19 vs. 0.65 events/100 person-years; hazard ratio, 0.56; p = 0.02), as well as lower levels of low-density lipoprotein-cholesterol than did non-users. The Kaplan-Meier curves revealed lower event rates in statin users (hazard ratio: 0.59 for MACCE and 0.56 for all-cause death). The incidence of myocardial infarction and coronary revascularization were lower in statin users.

CONCLUSIONS

Statin therapy for primary prevention was clearly associated with lower risk of cardiovascular events and all-cause death in individuals aged >75 years. These results support more active statin use in this population.

Inositol Polyphosphate Multikinase (IPMK), a Gene Coding for a Potential Moonlighting Protein, Contributes to Human Female Longevity

Biogerontological research highlighted a complex and dynamic connection between aging, health and longevity, partially determined by genetic factors. Multifunctional proteins with moonlighting features, by integrating different cellular activities in the space and time, may explain part of this complexity. Inositol Polyphosphate Multikinase (IPMK) is a potential moonlighting protein performing multiple unrelated functions. Initially identified as a key enzyme for inositol phosphates synthesis, small messengers regulating many aspects of cell physiology, IPMK is now implicated in a number of metabolic pathways affecting the aging process. IPMK regulates basic transcription, telomere homeostasis, nutrient-sensing, metabolism and oxidative stress. Here, we tested the hypothesis that the genetic variability of IPMK may affect human longevity. Single-SNP (single nuclear polymorphism), haplotype-based association tests as well as survival analysis pointed to the relevance of six out of fourteen genotyped SNPs for female longevity. In particular, haplotype analysis refined the association highlighting two SNPs, rs2790234 and rs6481383, as major contributing variants for longevity in women. Our work, the first to investigate the association between variants of IPMK and longevity, supports IPMK as a novel gender-specific genetic determinant of human longevity, playing a role in the complex network of genetic factors involved in human survival.

Total cholesterol and all-cause mortality by sex and age: a prospective cohort study among 12.8 million adults

It is unclear whether associations between total cholesterol (TC) levels and all-cause mortality and the optimal TC ranges for lowest mortality vary by sex and age. 12,815,006 Korean adults underwent routine health examinations during 2001–2004, and were followed until 2013. During follow-up, 694,423 individuals died. U-curve associations were found. In the TC ranges of 50–199 and 200–449 mg/dL, each 39 mg/dL (1 mmol/L) increase in TC was associated with 23% lower (95% CI:23%,24%) and 7% higher (6%,7%) mortality, respectively. In the age groups of 18–34, 35–44, 45–54, 55–64, 65–74, and 75–99 years, each 1 mmol/L higher TC increased mortality by 14%, 13%, 8%, 7%, 6%, and 3%, respectively (P < 0.001 for each age group), for TC ≥ 200 mg/dL, while the corresponding TC changes decreased mortality by 13%, 27%, 34%, 31%, 20%, and 13%, respectively, in the range < 200 mg/dL (P < 0.001 for each age group). TC had U-curve associations with mortality in each age-sex group. TC levels associated with lowest mortality were 210–249 mg/dL, except for men aged 18–34 years (180–219 mg/dL) and women aged 18–34 years (160–199 mg/dL) and 35–44 years (180–219 mg/dL). The inverse associations for TC < 200 mg/dL were stronger than the positive associations in the upper range.

How Common is Statin Use in the Oldest Old?

There is a lack of evidence surrounding the efficacy of statins in the oldest old (≥ 80 years of age). As such, there is controversy surrounding use of statins in this population. We sought to evaluate the prevalence of statin use in the oldest old worldwide to understand the scope of this issue. We searched PubMed and grey literature over the last 5 years. Studies had to report the prevalence of statin use in adults ≥ 80 years of age. The first author performed screening and extracted data. Our search produced 1870 hits; 14 articles were considered eligible. We found three studies of nursing home residents, eight studies of community-dwelling patients and three studies in the combined population (i.e., both community-dwelling patients and nursing home residents). The prevalence of statin use ranged from 17 to 39% in nursing home residents, 12 to 59% for community-dwelling patients and 18 to 45% in combined populations. Beyond age 80 years, the prevalence of statin use appeared to decrease with advancing age. Statin use was more common as secondary prevention compared with primary prevention. The prevalence of statin use in the oldest old has increased over recent decades. The increase in prevalence appears to be more pronounced in the oldest old compared with younger old, as reported by two studies. Statins are widely used in the oldest old despite the lack of evidence in this population. Given how common statin use is in the oldest old, clinical evidence surrounding their efficacy in this group is urgently needed to guide appropriate use and shared decision-making.

The reverse metabolic syndrome in the elderly: Is it a "catabolic" syndrome?

Traditional risk factors of cardiovascular death in the general population, including body mass index (BMI), serum cholesterol, and blood pressure are also found to relate to outcomes in the geriatric population, but in a differing direction. A higher body mass index, hypercholesterolemia and hypertension are not harmful but even permit better survival at advancing age. This phenomenon is called "reverse epidemiology" or "risk factor paradox" and is also detected in a variety of chronic disease states such as chronic heart failure. Accordingly, a low BMI, blood pressure and cholesterol values are associated with a worse prognosis. Several possible causes are hypothesized to explain this elderly paradox, but this phenomenon remains controversial and its underlying reasons are poorly understood. The aim of this review is to recognize the factors behind this intriguing phenomenon and analyse the consequences that it can bring in the management of the cardiovascular therapy in elderly patient. Finally, a new phenotype identified as "catabolic syndrome" has been postulated.

High Sensitivity Cardiac Troponin T and Cognitive Function in the Oldest Old: The Leiden 85-Plus Study

BACKGROUND

Impaired cardiac function has been related to accelerated cognitive decline in late-life.

OBJECTIVE

To investigate whether higher levels of high sensitivity cardiac troponin T (hs-cTnT), a sensitive marker for myocardial injury, are associated with worse cognitive function in the oldest old.

METHODS

In 455 participants of the population-based Leiden 85-plus Study, hs-cTnT was measured at 86 years. Cognitive function was measured annually during four years with the Mini-Mental State Examination (MMSE).

RESULTS

Participants in the highest gender-specific tertile of hs-cTnT had a 2.0-point lower baseline MMSE score than participants in the lowest tertile (95% confidence interval (CI) (95% CI 0.73-3.3), and had a 0.58-point steeper annual decline in MMSE during follow-up (95% CI 0.06-1.1). The associations remained after adjusting for sociodemographic and cardiovascular risk factors excluding those without a history of overt cardiac disease.

CONCLUSION

In a population-based sample of the oldest old, higher levels of hs-cTnT were associated with worse cognitive function and faster cognitive decline, independently from cardiovascular risk factors and a history of overt cardiac disease.

Appropriateness of statin prescription in the elderly

Statins, the most widely used drugs in the Western world, have become a pivotal component in the primary and secondary prevention of vascular diseases. Although benefits have been well documented in younger-than-75-year-old individuals, the value of statins in people aged >75years and over is controversial. The CTT meta-analysis calculated an absolute risk reduction of 0.6%/year per 38.7mg/dl reduction in LDL-C levels in patients aged >75years, that would translate into a number needed to treat of 167. However, the absolute effect of a 38.7mg/dl cholesterol lowering on the rate of annual ischemic heart disease mortality is 10-fold larger in older vs younger patients. In order to advise physician prescription, three major Guidelines have been published over the last few years, i.e. the AHA/ACC and the NLA in the US, and the ESC/EAS in Europe. Moreover, statin prescription in the elderly should also consider the cardiovascular outcomes of elderly patients reported in classical statin preventive trials which give important clues on adherence and persistence of use, as well as on drug safety. The present review discusses benefits of intensive vs moderate statin therapy, justifications for the use of aggressive lipid management in the very old and the use of statins in frail elderlies. The final decision on the therapeutic strategy with statins in elderlies at higher risk to develop cardiovascular events should be always based on a careful analysis of the patient's general health and on the presence of metabolic abnormalities or drug interactions potentially leading to risk.

Serum total cholesterol and risk of cardiovascular and non-cardiovascular mortality in old age: a population-based study

Background

Whether the suggested inverse association between total cholesterol and mortality in old age varies according to cause of death and use of cholesterol medications remains to be elucidated. The aim of this study was to assess the associations of total cholesterol with cardiovascular and non-cardiovascular mortality in old age, and to explore whether their associations vary by use of cholesterol-lowering medications.

Methods

The study participants included 3090 older adults (age ≥ 60 years, 63.7% women) from a population-based cohort study, i.e., the Swedish National study on Aging and Care in Kungsholmen, Stockholm. At baseline (2001–2004), data on demographic factors, lifestyles, cardiovascular risk factors, use of medications, global cognitive function, mobility limitation, and apolipoprotein E genotype were collected through interviews, clinical examinations, laboratory tests as well as from the Swedish national patient register. Vital statistics data (e.g., date and causes of death) till December 31, 2011 for all participants were derived from Swedish cause of death register. Data were analyzed using Cox proportional hazards model for all-cause mortality and Fine-Gray competing risks regression model for cause-specific mortality controlling for multiple potential confounders.

Results

During 23,196 person-years of follow-up (median per person, 7.5 years), 1059 (34.3%) participants died. Compared to normal total cholesterol (<5.18 mmol/l), borderline-high (5.18–6.21 mmol/l) and high (≥6.22 mmol/l) total cholesterol were associated with a decreased risk of all-cause mortality, with the multiple-adjusted hazard ratio (95% confidence interval, CI) of 0.71 (0.61–0.83) and 0.68 (0.57–0.80), respectively (P for trend <0.001). The competing risk regression models revealed that the reduced all-cause mortality associated with high total cholesterol (≥6.22 mmol/l)) was mainly due to the reduced risk of non-cardiovascular mortality (hazard ratio = 0.67, 95% CI = 0.51–0.88). These associations were statistically evident only among individuals without use of cholesterol-lowering medications.

Conclusions

The inverse association between high total cholesterol and reduced all-cause mortality in older adults is primarily due to non-cardiovascular mortality, especially among those who are not treated with cholesterol-lowering medications.

[Facing a dilemma in elderly complex and vulnerable patients: to stop or not to stop prevention?]

Objetivo

a) Conocer la prescripción preventiva (estatinas, antiagregantes, bifosfonatos, calcio/vitamina D y vitamina B₁₂) de los pacientes con patología crónica compleja (PCC) y de los pacientes con enfermedad crónica avanzada (ENCA) y esperanza de vida inferior a 12 meses que fallecieron durante el 2015. b) Valorar la correcta indicación en el uso de inhibidores de la bomba de protones (IBP) para determinar medicación evitable.

Diseño

Estudio transversal retrospectivo.

Emplazamiento

Cuatro centros de salud de Castellar del Vallès, Barcelona.

Participantes

Un total de 128 pacientes (70 ENCA y 58 PCC).

Variables

Fármacos activos en el momento de morir de los 6 grupos seleccionados, desprescripción (6 meses previos a la muerte por motivos de enfermedad crónica avanzada), indicación en prevención primaria o secundaria y adecuación en la prescripción IBP.

Resultados

Edad media en el momento de la muerte: 85,3 (10,3) años. El 40% de PCC/ENCA tomaban un antiagregante. En el 60% de los ENCA que tomaban un antiagregante no había evento cardiovascular previo. El 20% de PCC/ENCA tomaban una estatina y en el 48% de los casos por prevención primaria. La prescripción total de IBP fue del 67%, con indicación inadecuada del 49%. El 20% tomaban calcio/vitamina D y un 1,6% de los ENCA un bifosfonato. Hubo un 16% de desprescripción.

Conclusiones

Un porcentaje elevado de pacientes con enfermedad crónica avanzada y esperanza de vida corta siguen tomando tratamientos preventivos hasta sus últimos días, evitables en muchos casos y no exentos de efectos secundarios. Deberíamos aumentar la desprescripción de medicamentos con beneficios a largo plazo en este grupo de pacientes.

Extent and quality of drug use in community-dwelling people aged ≥75 years: A Swedish nationwide register-based study

Aims: It is important for district nurses and other health professionals in primary care to gain more insight into the patterns and quality of drug use in community-dwelling older people, particularly in 75-year-olds, who have been the target of preventive home visits. This study aimed to examine the extent and quality of drug use in community-dwelling older people and to compare drug use in 75-year-olds with that of older age groups. Methods: Data from 2013 on people aged ≥75 years were obtained from the Swedish Prescribed Drug Register. Those living in the community (671,940/739,734 people aged ≥75 years) were included in the study. Quality of drug use was assessed by using a selection of indicators issued by the Swedish National Board of Health and Welfare. Results: The prevalence of polypharmacy and of many drug groups increased with age, as did several indicators of inappropriate drug use. However some drug groups, as well as inappropriate drugs, were prevalent in 75-year-olds and declined with age, for example diabetes drugs, drugs with major anticholinergic effects and nonsteroidal anti-inflammatory drugs. Conclusions: The substantial use of some drugs as early as 75 years of age confirms the value of including drug use as a topic in preventive home visits to 75-year-olds. The finding that polypharmacy and many measures of inappropriate drug use increased with age in community-dwelling older people also underscores the importance of district nurses' role in continuing to promote safe medication management at higher ages.

Inception and deprescribing of statins in people aged over 80 years: cohort study

Objective

statin use over the age of 80 years is weakly evidence-based. This study aimed to estimate rates of statin inception and deprescribing by frailty level in people aged 80 years or older.

Methods

a cohort of 212,566 participants aged ≥80 years was sampled from the UK Clinical Practice Research Datalink. Statin inception was defined as a first-ever prescription in a non-statin user; deprescribing was defined as a last ever statin prescription more than 6 months before the end of participant records. Rates were estimated in a time-to-event framework allowing for mortality as a competing risk. Co-variates were age, gender, frailty category and prevention type.

Results

prevalent statin use increased from 2001-5 (9.9%) to 2011-15 (49.3%). Inception of statins in never-users was low overall at 2.4% per year (95% confidence interval (CI) 2.2-2.6%) and declined with age. Deprescribing of statins in current users occurred at a rate of 5.6% (95% CI 5.4-5.9%) per year overall and increased with age, reaching 17.8% per year (95% CI 6.7-28.9%) among centenarians. Deprescribing was slightly higher for primary prevention (6.5% per year) than secondary prevention (5.2% per year) indications (P < 0.001). Deprescribing increased with frailty level being 5.0% per year in 'fit' participants and 7.1% in 'severe' frailty (P < 0.001).

Conclusions

statin use has increased in the over 80s but deprescribing is common and increases with age and frailty level. These paradoxical findings highlight a need for better evidence to inform statin use and discontinuation for people aged ≥80 years.

Effect of Statin Treatment vs Usual Care on Primary Cardiovascular Prevention Among Older Adults: The ALLHAT-LLT Randomized Clinical Trial

IMPORTANCE

While statin therapy for primary cardiovascular prevention has been associated with reductions in cardiovascular morbidity, the effect on all-cause mortality has been variable. There is little evidence to guide the use of statins for primary prevention in adults 75 years and older.

OBJECTIVES

To examine statin treatment among adults aged 65 to 74 years and 75 years and older when used for primary prevention in the Lipid-Lowering Trial (LLT) component of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT-LLT).

DESIGN, SETTING, AND PARTICIPANTS

Post hoc secondary data analyses were conducted of participants 65 years and older without evidence of atherosclerotic cardiovascular disease; 2867 ambulatory adults with hypertension and without baseline atherosclerotic cardiovascular disease were included. The ALLHAT-LLT was conducted from February 1994 to March 2002 at 513 clinical sites.

INTERVENTIONS

Pravastatin sodium (40 mg/d) vs usual care (UC).

MAIN OUTCOMES AND MEASURES

The primary outcome in the ALLHAT-LLT was all-cause mortality. Secondary outcomes included cause-specific mortality and nonfatal myocardial infarction or fatal coronary heart disease combined (coronary heart disease events).

RESULTS

There were 1467 participants (mean [SD] age, 71.3 [5.2] years) in the pravastatin group (48.0% [n = 704] female) and 1400 participants (mean [SD] age, 71.2 [5.2] years) in the UC group (50.8% [n = 711] female). The baseline mean (SD) low-density lipoprotein cholesterol levels were 147.7 (19.8) mg/dL in the pravastatin group and 147.6 (19.4) mg/dL in the UC group; by year 6, the mean (SD) low-density lipoprotein cholesterol levels were 109.1 (35.4) mg/dL in the pravastatin group and 128.8 (27.5) mg/dL in the UC group. At year 6, of the participants assigned to pravastatin, 42 of 253 (16.6%) were not taking any statin; 71.0% in the UC group were not taking any statin. The hazard ratios for all-cause mortality in the pravastatin group vs the UC group were 1.18 (95% CI, 0.97-1.42; P = .09) for all adults 65 years and older, 1.08 (95% CI, 0.85-1.37; P = .55) for adults aged 65 to 74 years, and 1.34 (95% CI, 0.98-1.84; P = .07) for adults 75 years and older. Coronary heart disease event rates were not significantly different among the groups. In multivariable regression, the results remained nonsignificant, and there was no significant interaction between treatment group and age.

CONCLUSIONS AND RELEVANCE

No benefit was found when pravastatin was given for primary prevention to older adults with moderate hyperlipidemia and hypertension, and a nonsignificant direction toward increased all-cause mortality with pravastatin was observed among adults 75 years and older.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00000542.

Insights Into the Current Management of Older Adults With Type 2 Diabetes in the Ontario Primary Care Setting

OBJECTIVE

The Goal Oriented controL of Diabetes in the Elderly populatioN (GOLDEN) Program assessed the management of older persons with type 2 diabetes in Canadian primary care.

METHODS

Data were extracted from the records of 833 consecutively identified persons 65 years of age or older who had type 2 diabetes and were taking 1 antihyperglycemic agent or more; they were managed by 64 physicians from 36 Ontario clinics.

RESULTS

More than half (53%) had glycated hemoglobin (A1C) levels of 7.0% or lower, 41% had blood pressure levels below 130/80 mm Hg, and 73% had low-density lipoprotein levels of 2.0 mmol/L or lower; 19% met all 3 criteria. Over the past year, 11% had been assessed for frailty, 16% for cognitive dysfunction and 19% for depression; 88% were referred for eye checkups, and 83% had undergone foot examinations. One-tenth were taking 4 or more antihyperglycemic agents, 87% statins and 52% an angiotensin-converting enzyme inhibitor. More than half of those with high clinical complexity had A1C levels of 7.0% or lower; of these, one-third were taking a sulfonylurea, and one-fifth were taking insulin. In the patients with A1C levels of 7.0% or above and low clinical complexity, there was often no up-titration or initiation of additional antihyperglycemic agents.

CONCLUSIONS

Older persons with type 2 diabetes often have multiple comorbidities. Unlike eye and foot examinations, there was less emphasis on evaluating for frailty, cognitive dysfunction and depression. The GOLDEN patients had generally well-controlled glycemic, blood pressure and cholesterol profiles, but whether these would be reflected in a "sicker" population is not known. Personalized strategies are necessary to avoid undertreatment of "healthy" older patients and overtreatment of the frail elderly.

Algorithm for predicting CHD death risk in Turkish adults: conventional factors contribute only moderately in women

OBJECTIVE

To assist the management strategy of individuals, we determined an algorithm for predicting the risk of coronary heart disease (CHD) death in Turkish adults with a high prevalence of metabolic syndrome (MetS).

METHODS

The risk of CHD death was estimated in 3054 middle-aged adults, followed over 9.08±4.2 years. Cox proportional hazard regression was used to predict risk. Discrimination was assessed using C-statistics.

RESULTS

CHD death was identified in 233 subjects. In multivariable analysis, the serum high-density lipoprotein-cholesterol (HDL-C) level was not predictive in men and the non-HDL-C level was not predictive in women. Age, presence of diabetes, systolic blood pressure ≥160 mm Hg, smoking habit, and low physical activity were predictors in both sexes. The exclusion of coronary disease at baseline did not change the risk estimates materially. Using an algorithm of the 7 stated variables, individuals in the highest category of risk score showed a 19- to 50-fold higher spread in the absolute risk of death from CHD than those in the second lowest category. C-index of the model using age alone was as high as 0.774 in men and 0.836 in women (p<0.001 each), while the incorporation of 6 conventional risk factors contributed to a C-index of 0.058 in males and 0.042 in females.

CONCLUSION

In a middle-aged population with prevalent MetS, men disclosed anticipated risk parameters (except for high HDL-C levels) as determinants of the risk of CHD death. On the other hand, serum non-HDL-C levels and moderate systolic hypertension were not relevant in women. The moderate contribution of conventional risk factors (beyond age) to the estimation of the risk of CHD death in women is consistent with the operation of autoimmune activation.

Little contribution of conventional factors in an algorithm to predicting death risk in Turkish adults

OBJECTIVE

Determinants of risk of death are highly relevant for the management strategy of individuals. We aimed to determine an algorithm for predicting risk of death in Turkish adults who have a high prevalence of metabolic syndrome (MetS).

METHODS

Nine-year risk of death was estimated in 3348 middle-aged adults, followed over 8.81±4.2years. Cox proportional hazard regression was used to predict risk of death. Discrimination was assessed using C-statistics.

RESULTS

Death occurred in 565 subjects. In multivariable analysis, high-density lipoprotein (HDL) and non-HDL cholesterol levels were not predictive in either sex; in women, current smoking was also not predictive. Age, presence of diabetes, systolic blood pressure ≥160mmHg and low physical activity were predictors in both sexes, beyond smoking status in men. Exclusion of coronary disease at baseline did not change risk estimates materially. Using an algorithm of the stated 7 variables showed an 11- to 18-fold spread in the absolute risk of dying among individuals in the highest than in the lowest of 4 risk score categories. C-statistics of the model using age alone was 0.790 in men, 0.808 in women (p<0.001 each), while the incorporation of 6 conventional risk factors contributed to C-index was >0.020 in males and 0.009 in females.

CONCLUSIONS

In a middle-aged population with prevalent MetS, serum lipoproteins and, in women, smoking status, were not relevant for the risk of death. The contribution of conventional risk factors beyond age to estimating risk of death was modest among Turkish men, and little in women in whom autoimmune activation is operative.

General Practitioners' Decision Making about Primary Prevention of Cardiovascular Disease in Older Adults: A Qualitative Study

BACKGROUND

Primary cardiovascular disease (CVD) prevention in older people is challenging as they are a diverse group with varying needs, frequent presence of comorbidities, and are more susceptible to treatment harms. Moreover the potential benefits and harms of preventive medication for older people are uncertain. We explored GPs' decision making about primary CVD prevention in patients aged 75 years and older.

METHOD

25 GPs participated in semi-structured interviews in New South Wales, Australia. Transcribed audio-recordings were thematically coded and Framework Analysis was used.

RESULTS

Analysis identified factors that are likely to contribute to variation in the management of CVD risk in older people. Some GPs based CVD prevention on guidelines regardless of patient age. Others tailored management based on factors such as perceptions of prevention in older age, knowledge of limited evidence, comorbidities, polypharmacy, frailty, and life expectancy. GPs were more confident about: 1) medication and lifestyle change for fit/healthy older patients, and 2) stopping or avoiding medication for frail/nursing home patients. Decision making for older patients outside of these categories was less clear.

CONCLUSION

Older patients receive different care depending on their GP's perceptions of ageing and CVD prevention, and their knowledge of available evidence. GPs consider CVD prevention for older patients challenging and would welcome more guidance in this area.

Statin Use and Self-Reported Hindering Muscle Complaints in Older Persons: A Population Based Study

Purpose

Statins are widely used by older persons in primary and secondary prevention of cardiovascular disease. Although serious adverse events are rare, many statin users report mild muscle pain and/or muscle weakness. It’s unclear what impact statins exert on a patient’s daily life. Research on statin related side effects in older persons is relatively scarce. We therefore investigated the relation between statin use and self-reported hindering muscle complaints in older persons in the general population.

Methods

The present research was performed within the Integrated Systematic Care for Older Persons (ISCOPE) study in the Netherlands (Netherlands trial register, NTR1946). All registered adults aged ≥ 75 years from 59 participating practices (n = 12,066) were targeted. Information about the medical history and statin use at baseline and after 9 months was available for 4355 participants from the Electronic Patient Records of the general practitioners. In the screening questionnaire at baseline we asked participants: ‘At the moment, which health complaints limit you the most in your day-to-day life?’ Answers indicating muscle or musculoskeletal complaints were coded as such. No specific questions about muscle complaints were asked.

Results

The participants had a median age of 80.3 (IQR 77.6–84.4) years, 60.8% were female and 28.5% had a history of CVD. At baseline 29% used a statin. At follow-up, no difference was found in the prevalence of self-reported hindering muscle complaints in statin users compared to non-statin users (3.3% vs. 2.5%, OR 1.39, 95% CI 0.94–2.05; P = 0.98). Discontinuation of statin use during follow-up was independent of self-reported hindering muscle complaints.

Conclusion

Based on the present findings, prevalent statin use in this community-dwelling older population is not associated with self-reported hindering muscle complaints; however, the results might be different for incident users.