Can Statins Prevent Heart Disease and Stroke in Older Adults?
Heart disease is the leading cause of death in the United States for both men and women, according to the Centers for Disease Control and Prevention (CDC). Two of the biggest risk factors for heart disease are high blood pressure (hypertension) and high cholesterol. Lifestyle changes like a healthy diet, regular exercise, and quitting smoking can help improve both.
If lifestyle changes don’t make an impact, medications can help. For high cholesterol, the most prescribed medications are known as statins. The CDC’s Million Hearts Initiative estimates that statins can reduce a person’s risk of heart attack or stroke by 50%. Yet not everyone who can benefit from a statin may have been prescribed the medication.
“Despite their effectiveness, statins haven’t been widely prescribed for people who don’t have pre-existing heart disease. There was doubt over whether they should be used for patients with other risk factors beyond heart disease, partly because of a lack of data on these patients. There was also concern about side effects,” explains Ariela Orkaby, MD, MPH, a Mass General Brigham geriatrician. Geriatricians specialize in treating older patients and Dr. Orkaby cares for patients at Brigham and Women’s Hospital.
Dr. Orkaby and colleagues have recently published studies on statins that show promising results. One study showed that statins may prevent heart attacks and strokes in patients with chronic kidney disease (CKD). The other study found that statins lowered the risk of heart attacks, stroke, and death in older adults experiencing a condition known as frailty. Frailty in older adults occurs when they become weak and find everyday activities more difficult. These two groups of people are both at high risk for developing heart disease in the future, even if they don’t currently have high cholesterol or heart disease.
Dr. Orkaby’s research shows that statins can help reduce the risk of heart attack and stroke for even more patients.
What are statins?
The liver produces cholesterol. It’s a type of fat that carries molecules and other chemical signals through the bloodstream. It’s also a component of Vitamin D, hormones, and cell membranes. Your liver makes cholesterol with building blocks from food, like sugars and fats. If there’s too much extra cholesterol in the diet, it can build up in the arteries and cause coronary artery disease.
Statins work in the liver to prevent cholesterol from forming. Statins also help the liver reduce the levels of cholesterol already in the blood. It lowers the levels of LDL, commonly known as “bad” cholesterol, and raises the levels of HDL, known as “good” cholesterol. Other medications can help manage cholesterol levels, but statins are the most widely used and the most effective. Statins can take up to 2.5 years to show their full effects. The longer you take statins, the greater the benefit.
Studying statins and chronic kidney disease (CKD)
Heart disease is the leading cause of death for older adults with CKD, but these patients weren’t included in many trials studying statins. For patients with CKD and no history of heart disease, it was unclear if statins could help as a way to prevent heart disease.
Dr. Orkaby and her colleagues analyzed the effects of statins on a group of almost 15,000 veterans, aged 65 years or older. They all had CKD and no history of heart disease. Using data from health care and insurance systems, they simulated a trial where doctors prescribed part of the group statins. The control group did not take statins. The group that was prescribed statins had a 9% lower risk of dying from any cause.
“More research needs to be done, including a randomized clinical trial, but these results are very promising. The data indicate that patients with CKD may have a substantial benefit from starting a statin,” says Dr. Orkaby.
Studying statins and frailty in older adults
As people get older, it’s natural for their bodies to change and not function the way they used to. Not all older adults experience frailty, but those who become frail are at a higher risk for falls, disability, needing care in a hospital, and death. Being frail is also a risk factor for heart disease. Frailty can be a vicious cycle: as a person becomes frail, it’s harder for them to participate in the activities and exercise that can help prevent frailty in the first place. Frailty can also get worse due to chronic conditions like diabetes or dementia.
Some signs and symptoms of frailty include:
Slower walking speed
Weakness and reduced grip strength
Unintentional weight loss
Reduced physical activity
Fatigue
“Frailty on its own is a risk factor for heart disease, but it’s not traditionally accounted for when assessing risk,” notes Dr. Orkaby.
Like older adults with CKD, older adults with frailty haven’t taken part in many studies on statins. “The 2014 cholesterol guidelines stopped at age 75 because studies didn’t include many people over 75, and very few who were frail. But there’s no magical cut-off for high cholesterol or risk of a heart attack or stroke at age 75. Those older patients, especially those with frailty, could still see a benefit,” Dr. Orkaby explains.
In Dr. Orkaby’s study, she and her colleagues studied the health records of more than 710,000 veterans from 2005-2017. They identified more than 86,000 patients who qualified as frail. They analyzed the heart disease outcomes of two groups of frail patients: those who were prescribed statins, and those who weren’t. Their results showed that frail adults taking statins had a 39% lower risk of mortality and a 14% lower risk of a first heart attack or stroke.
“Because people who are frail are at the highest risk of a heart attack, stroke, or death, they may have the greatest benefit of staring a statin,” says Dr. Orkaby.
How do you know if you should take statins?
Over time, there has been a trend among doctors to de-prescribe or delay prescribing statins, especially for older patients. In addition to the lack of data on these patients, doctors were also concerned about possible side effects like muscle pains. Dr. Orkaby has found these side effects to be rare and manageable. “Aches and pains are a regular effect of aging. It’s not necessarily a sign that you should stop taking this medication,” she says.
Dr. Orkaby’s research shows that even more people may benefit from statins. She recommends that patients speak to their primary care provider (PCP) or cardiologist about their current chronic health conditions and their family history of heart disease. “People should be aware of their own personal levels of risk. Family history is most important in younger individuals, especially those in their 40s and 50s,” she says.
PREVENTABLE trial: Ongoing statin research for adults over 75
Dr. Orkaby’s research into statins continues with the PREVENTABLE trial, a large ongoing study of statins in adults over the age of 75.
“Our results add to the data that statins have a protective effect for people who haven’t yet had heart disease. There are real benefits to prescribing these medications for prevention of heart disease. We also believe that these medications may help improve quality of life and extend life expectancy, which we are testing in the PREVENTABLE trial,” says Dr. Orkaby.
