Thread by @iniya_rajendran

Continuing statins for primary prevention in our elderly (age >75) patients – yea or nay?
A #tweetorial inspired by @laxswamy @tony_breu @DocBrock9 @ShreyaTrivediMD @DrPoorman @RZChipMD, poll responders and retweeters who made my noon conference talk a huge success

For primary prevention of ASCVD, USPSTF recommends the use of a low-to moderate-dose statin in 40-75-year-old patients with a calculated ASCVD score of >10%.
uspreventiveservicestaskforce.org/Page/Document/…

ACC/AHA extend this to patients up to the age of 79 but there is uncertainty in practice. Patients >75 years have been poorly represented in large statin trials leading to physicians extrapolating treatment algorithms used for their younger patients.
acc.org/latest-in-card…

Let’s look at the evidence for and against the use of statins for primary prevention in elderly patients (study selection does not meet systemative review guidelines😅).

ALLHAT-LLT: A secondary analysis of an RCT. It showed no benefit when pravastatin was given for primary prevention to adults >65 years and a nonsignificant direction toward increased all-cause mortality in adults >75 years and older.
ncbi.nlm.nih.gov/pubmed/28531241

Meta-analysis: 28 RCTs were analyzed to show that statin use had “less definitive direct evidence of benefit” because of a trend towards a smaller proportional reduction in vascular events among patients >75 when used for primary prevention.
ncbi.nlm.nih.gov/pubmed/30712900

Following two studies provide evidence FOR the use of statins. However, the study designs are not as rigorous as above and I took the liberty of giving them names

Spanish-diabetes study: A cohort study on diabetic pts on statin therapy had a reduced incidence of ASCVD, by 24%, and all-cause mortality, by 16% (absolute reduction in cardiovascular events of about 7 per 1000 people treated for one year)
ncbi.nlm.nih.gov/pubmed/30185425

French-discontinuation study: Also a cohort study of age >75 in which statin discontinuation (>3months) was associated with a 33% increased risk of admission for cardiovascular events in primary prevention patients.
ncbi.nlm.nih.gov/pubmed/31362307

Could the side effect profile be a deal-breaker? The short answer is no
Statins are associated with a modest risk of new-onset diabetes, increased risk of muscle symptoms leading to injuries and falls, liver injury, polypharmacy to name a few.

However, newer studies have shown that the rates of statin symptoms are NOT higher in older patients, no evidence was found on cognitive decline function, renal deterioration or risk of cataracts.
ncbi.nlm.nih.gov/pubmed/29718253

When there is conflicting evidence, what do you do? Ask #medtwitter

Poll takeaways
1. Shared decision making is always the right answer
2. Geriatricians want more data - functional status, frailty score, preference for longevity vs QOL
3. The deprescribes were in the no guidelines=no Rx zone
4. The refillers: If they were tolerating, why stop?

Well, this is a bit anti-climactic! I gave you a bunch of for and against arguments but did not put my nickel down (classic resident move). Don't despair! There is an ongoing RCT to study this very question -watch this space! Results in 2022
clinicaltrials.gov/ct2/show/NCT02…

Until then, shared decision making and discussing risk vs benefit for individual patients is the way forward! (unless you want to go down the route of coronary artery calcium score and/or a carotid plaque imaging score – I am not sure I do just yet)
ncbi.nlm.nih.gov/pubmed/29019063

Does this #tweetorial change your mind? Let me know and thanks for reading!
80 y/o male who is on a statin for PRIMARY prevention comes in for a physical. Re: statin would you