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DR. ARONOW makes a strong case for lowering the target low-density lipoprotein level for patients treated with statins (1). I will limit my comments to one aspect of his discussion—when and how to treat very old people. The current National Cholesterol Education Program (NCEP) guidelines call for lowering the cholesterol of those patients who have a 10-year risk for coronary disease of .20% (2). Might that not include all very old people? The figure below presents 10-year risks of mortality from heart disease as a function of age and gender. At age 75, men have a 16% and women a 12% chance of dying from heart disease in the next 10 years. And that is just mortality; it doesn’t include chance of developing nonfatal heart disease, which is at least as high as the mortality rate. This raises a question: Is it possible to prospectively define a subset of 75 year olds that do not have a .20% 10year risk of heart disease? I doubt it. If not, then does that mean that all 75 year olds should be on statins? Even if it is possible to define such a group of 75 year olds, does anyone think they can identify a group of 80 year olds with a ,20% 10-year cardiovascular disease risk? This is the problem encountered when one takes guidelines originally constructed with one population in mind (the middle aged) and applies it to another population (the very old). It is certainly possible that someday we will recommend that all 75 year olds be on statins, but we do not know that at this time. What we do know from the MRC/BHF (Medical Research Council/British Heart Foundation) trials is that 70–80 year olds with preexisting coronary disease and/or other vascular disease and/or diabetes and elevated cholesterol experience a 5.1% absolute reduction in new vascular events over 5 years when treated with statins (3). The PROSPER (Prospective Study of Pravastatin in the Elderly at Risk) study of 70–82 year olds with a somewhat lower prevalence of risk factors reported an absolute reduction in new heart attacks or stroke of 2.1% over 3 years of follow-up (4). These are impressive results and justify more aggressive treatment of older people with elevated cholesterol plus vascular disease or diabetes. What we do not know is what to do with those persons older than age 80. A reasonable approach would be to treat octogenarians if they resemble the subjects of the MRC/BHF trial; i.e., preexisting vascular disease and/or diabetes plus elevated cholesterol. Dr. Aronow has published a series of observational studies of institutionalized men and women with a mean age of 81, showing that those treated with statins had lower heart attacks, strokes, and heart failure than those not treated (5–9). Selection bias would be powerful in such a very old, institutionalized population. I doubt that we can learn about safety and efficacy of statins in various categories of very old people without randomized controlled trials.

the journals of gerontology. series a, biological sciences and medical sciences

Aronow's "Should the NCEP III Guidelines Be Changed in Elderly and Younger Persons at High Risk for Cardiovascular Events?": What Do We Do for the Very Old?