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John is a 85 year old living in his own home who has a history
of hypertension, ST elevated myocardial infarction (STEMI), and
osteoarthritis. He is currently prescribed paracetamol 1g three times a
day, metoprolol 50mg twice a day, perindopril 2.5 mg daily, atorvastatin
80 mg daily, aspirin 100mg daily, clopidogrel 75 mg daily. Johns BP is
125/75mm Hg. His doctor would like to de-prescribe some of his medicines,
and is considering ceasing the statin. John has noticed no muscle pain or
confusion or other adverse effects from his statin.
De-prescribing statins for primary
prevention in the elderly or for
secondary prevention in the elderly with
poor quality of life is often appropriate,
but what should we do for secondary
prevention in highly functioning
patients like John?
De-prescribing for elderly patients
has become more prevalent.
is a positive move. The problems of
polypharmacy in elderly patients has been
extensively discussed in the literature.
Statins are often the target drug class for
de-prescribing in the elderly.
Those who argue for de-prescribing
of statins in the elderly derive their
conclusions from four main premises.
1. There is no evidence for the use of
statins in the elderly.
2. Elderly patients are less likely to
benefit compared to younger patients
in terms of relative and absolute risk
reductions in cardiovascular events.
3. Elderly patients need to live for five
years to see any benefit from statins.
Those with uncertain life expectancies
are thus unlikely to benefit from
4. There is no reason to use statins in this
cohort as all they do is extend life, and
they do not prevent morbidity.
Premise 1: There is no evidence for the
use of statins in the elderly.
Summary of trials of statins in the elderly.
It is often claimed that there in no
evidence for statins in the elderly. This is
true when we look at the landmark
The CARE study which compared
pravastatin against placebo recruited
9,000 patients between 65 and 75 years
of age, and no patients over 75 years of
The Heart Protection Study (HPS) which
compared simvastatin against placebo
had 5,806 patients between 70 and
80 years of age and zero patients above
80 years of age.
The 4S study which also compared
simvastatin against placebo had zero
patients above 70 years of age.5
Prosper was a study designed to
evaluate the benefit of pravastatin
40 mg daily in a high risk group
(primary or secondary prevention) of
elderly patients (mean age 75 years,
age range 70–82 years).
Risk Reduction (RRR) for the primary
endpoint (a composite of death
and cardiovascular events) was 15%
and the Absolute Risk Reduction
(ARR) for the primary endpoint was
2.1%. This difference was driven by
a difference in nonfatal myocardial
Karl Winckel is a Conjoint Lecturer at the School of
Pharmacy, Pharmacy Australia Centre of Excellence,
The University of Queensland in Brisbane.
I would like to acknowledge Matthew Percival for his
advice and review of this article.
infarction. Prosper failed to show a
significant effect on stroke. This lack of
effect on stroke was hypothesised to be
due to the weak statin used in Prosper,
and so SPACRL was designed to answer
SPARCL was a RCT involving 4,700 patients
(2200 over 65 years of age) testing
whether atorvastatin 80 mg daily reduces
stroke in patients without coronary heart
There was a 16% RRR in nonfatal
or fatal stroke (ARR 1.9%). All-cause
mortality was not reduced.
The ARR in
nonfatal stroke was greater than the ARR
in fatal stroke (1.4% vs 0.7%).
Perhaps one of the most important
yet largely unknown study of statins in
the elderly is SAGE.
SAGE enrolled 893
patients with myocardial ischaemia aged
between 65 years and 85 years of age,
and compared atorvastatin 80 mg daily
with pravastatin 40 mg daily. The RRR
for all-cause mortality with atorvastatin
compared to pravastatin was 66% with an
ARR of 2.7%. The RRR for major adverse
cardiovascular events was 29% with
atorvastatin vs pravastatin (ARR 3.1%).
SAGE suggests that in a cohort of elderly
people with myocardial ischaemia, higher
potency statins are more effective than
lower potency statins.
MIRACL compared atorvastatin 80 mg
daily with placebo in patients with
acute coronary syndrome (ACS).
MIRACL enrolled 3,086 patients with
1,672 patients being over the age of 65.
There was a 2.9% ARR in a composite
endpoint of death, myocardial infarction
or hospitalisation in the over 65 years of
age cohort, with the greatest effect in the
over 80 years of age cohort.
The statement that there is no evidence
for the use of statins in the elderly is
misleading. There is enough data in the
65 years to 85 years group to help guide
treatment decisions in this population
An argument to continue
statins for secondary
prevention in the elderly
BY KARL WINCKEL
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