En español | When she was 74, Barbara Rivers, a former schoolteacher and administrator in Charlotte, North Carolina, was prescribed a statin — one in the popular class of drugs that lower cholesterol. This was after tests had shown that her LDL (bad) cholesterol was creeping up above the normal range.
Now 89, Rivers has been on the drug ever since. “It seems to be doing its job, and it hasn't created any side effects,” she says. “My doctor says my cholesterol is amazingly low."
Rivers is one of millions of Americans who take these lipid-lowering medications, which work by slowing down the liver's production of cholesterol overall while increasing its ability to remove LDL cholesterol in particular from the blood. By doing this, they also appear to help prevent heart attacks and strokes by keeping plaques from breaking apart and forming clots that can move to the heart or brain.
While all those benefits sound good, doctors may hesitate to prescribe this type of drug for people over 75 in the absence of clear-cut guidelines from the American College of Cardiology and the American Heart Association. Those state that you should take a statin if:
- You've had a heart attack or stroke or you have peripheral artery disease.
- Your LDL cholesterol level is 190 mg/dL or higher.
- You are 40 to 75 years old with diabetes.
- You are 40 to 75 years old with a high risk of developing heart disease or stroke and have an LDL cholesterol level of 70 mg/dL or higher.
According to the guidelines, after age 75 you should have a workup with your doctor and a discussion of risks and benefits. That's due to a lack of studies assessing the safety and effectiveness of statins for people in this age group.
"There are no clear guidelines after 75,” says cardiologist Dara Lee Lewis, M.D., an associate physician and instructor in medicine at Brigham and Women's Hospital in Boston. “And it has been difficult as a provider, because this is who our patients are.” In fact, the older you are, the greater your risk for a variety of heart ills. “About 1 in 3 Americans will ultimately die from cardiovascular disease,” Lewis says. “So everyone over 75 is at high risk.”
On the other hand, older patients are more likely to be on multiple medications that can interact with statins. And there's some evidence that this age group may be more prone to statin side effects, such as muscle pain, an increased risk of diabetes, and liver problems.
New drug data show benefits
But the picture is becoming clearer. A slew of recent studies have shown that statins may have significant benefits in older age groups. “Your physiology doesn't suddenly change when you turn 75 years of age,” says Steven Nissen, M.D., chair of cardiovascular medicine at the Cleveland Clinic.
In data released in July, researchers followed more than 320,000 veterans age 75 and older for about seven years. “There was a 25 percent lower risk of dying from any cause among those who were taking a statin, compared to those who never did — and a 20 percent lower risk of dying from a cardiovascular event, such as a heart attack or stroke, among those who started taking a statin after age 75,” says the study's lead author, Ariela Orkaby, M.D., MPH, a physician scientist at the VA Boston Healthcare System and assistant professor of medicine at Brigham and Women's Hospital.
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What's more, in a 2019 French study, people ages 75 to 79 experienced a health issue after going off these cholesterol-lowering medications. Over a follow-up period of up to four years, 10 percent of those who discontinued their statins were later admitted to the hospital for cardiovascular problems, compared with only 8 percent of those who stayed on the drugs.
Similarly, an Israeli study, also published in 2019, in the Journal of the American Geriatrics Society, found that older people who adhered to their statin prescription had a 34 percent lower chance of an early death from any cause than those who stopped taking the drug.
Cardiologists are quick to point out that such research, showing correlations, isn't the strongest type of data. Still, the studies are compelling. “They've been so consistent,” says Lewis. “Across the board, statins appear to [lower risk] about 20 to 30 percent, compared to placebo, no matter how old you are and no matter your baseline level of risk."
A new NIH/Duke University study is expected to resolve the age question. Called “Pragmatic Evaluation of Events and Benefits of Lipid-Lowering in Older Adults (PREVENTABLE),” the study will enroll 20,000 adults age 75 and older to investigate the overall benefits and risks of statins — not just for their heart health but for their neurological function. The results won't be available for several years, but in the meantime, the American College of Cardiology and the American Heart Association call statins a reasonable choice for older people when other measures have not worked to bring down their cholesterol levels. With one caveat: It depends on the patient.
"When I see a patient over 75 who I believe has a relatively long life expectancy and who has elevated cholesterol and maybe some other risk factors, like diabetes or hypertension, I discuss with them the pros and cons of statins and suggest we try one,” says Nissen. “If they tolerate it well, without any adverse effects, then I think I've done them a lot of good.”
It's a different story if a patient is very frail or is not expected to live for more than a few years because of advanced illnesses. In that case, a statin may or may not be the right choice.
"I do try to twist people's arms to get them on one, especially if they're diabetic or have a lot of other risk factors,” Lewis agrees. “But I watch them much more closely, and I worry about them more."
If statin side effects become an issue, the prescription can often be tweaked. “For most people who say that they're statin intolerant, there's usually an option,” says Orkaby, who adds that there are some that are considered lower or moderate intensity. “It's finding the sweet spot of what works for every patient."
While statins aren't for everybody, Nissen says, there's a role for them — at any age. “I am doing the best scientific work of my life and will probably be doing this for 10 more years,” he says. “I'm taking a statin, and when I turn 75 I have no intention of stopping the stuff.”