Discontinuing statins for primary prevention in older adults

The major randomized controlled trials (RCTs) that established the benefits of statins in preventing atherosclerotic cardiovascular disease (ASCVD) generally did not enroll persons older than 75 years. Once a patient who has been taking a statin for primary prevention reaches that age, are there additional benefits to continuing it, or conversely, are there harms associated with discontinuing? In 2020, a systematic review of international guidelines on cardiovascular disease prevention found “little specific guidance for physicians who are considering statin discontinuation in older adults in the context of declining health status and short life expectancy.”

A 2024 systematic review identified 35 observational studies and a single RCT comparing statin discontinuation to continuation. The observational studies showed that statin discontinuation in all age groups was associated with statistically significant increases in all-cause mortality (hazard ratio (HR) = 1.92), cardiovascular mortality (HR = 1.63), and cardiovascular events (HR = 1.31), with similar results in adults 75 years and older. The single RCT was performed in 381 older adults with deteriorating functional status and an estimated life expectancy of 1 month to 1 year. 60-day mortality was similar between the groups (23.8% with discontinuation vs 20.3% with continuation, p=0.36), and quality of life was better in the group no longer taking statins.

An expert panel recently utilized this limited evidence base to create a clinical practice guideline on deprescribing statins in older persons. A synopsis of the guideline is available in an algorithm. The guideline suggests deprescribing statins in older adults at end-of-life and continuing them for primary and secondary prevention in other adults older than 65. Several factors may prompt a conversation about statins: frailty, pill burden, functional limitations, cognitive impairment, complex care needs, and advanced illness (eg, cancer). Select patients with life expectancies greater than 1 year may reasonably decide to discontinue statins based on their personal goals and the value they assign to preventing future cardiovascular events.

The results of a pragmatic, open-label RCT published this month in The Lancet Healthy Longevity support individualized decision-making regarding statin continuation in older adults. 1,180 French adults 75 years and older who had been taking a stain for primary prevention for at least 1 year and had no evidence of dementia or another progressive life-limiting disease were randomly assigned to stop or continue taking statins. After 3 years, there were no statistical differences in all-cause mortality or cardiovascular events between the groups. However, the group that discontinued statins had no advantages in quality or life, cognitive function, functional status, symptom burden, or adverse events.

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This post first appeared on the AFP Community Blog.