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High or abnormal cholesterol levels, inflammation, and endothelial dysfunction play a key role in atherosclerosis and plaque build-up, the most common cause of heart attacks and strokes. (Endothelial dysfunction refers to an impaired functioning of the inner lining of blood vessels on the surface of the heart. The result is inappropriate narrowing of these vessels instead of enlargement, which restricts blood flow.) Or good cholesterol); triglycerides (a byproduct of excess calories consumed, which are stored as fat); and low density lipoproteins (LDL or bad cholesterol).
It is well established that lowering LDL cholesterol, sometimes whether or not you have high cholesterol, improves cardiovascular outcomes. But do older people get the same benefits from lowering cholesterol and face additional risks?
Lowering LDL reduces cardiovascular risk
Studies have consistently shown that lowering LDL cholesterol reduces the risk of cardiovascular death, heart attacks, strokes, and the need for heart catheterizations or bypass surgery. This has been shown in patients with established coronary artery disease, as well as in high-risk patients without coronary artery disease.
Lifestyle changes can lower cholesterol levels by about 5% to 10%, while cholesterol lowering drugs can lower LDL cholesterol by 50% or more. Therefore, while lifestyle modifications like eating a heart-healthy diet (the Mediterranean diet, for example), stopping smoking, regular exercise, and weight loss are key to reducing cardiovascular risk, medications are often needed to provide additional cardiovascular protection.
Statins, including atorvastatin (Lipitor), simvastatin (Zocor), rosuvastatin (Crestor), and pravastatin (Pravachol), are the main treatment for lowering LDL. Statins work by reducing the production of cholesterol in your own body, which helps the liver to absorb LDL from the bloodstream. But not all of the benefits of statins can be explained by the decrease in LDL alone. Studies show that statins have favorable effects on inflammation, endothelial dysfunction, and plaque stabilization (when plaque breaks down it can cause a heart attack or stroke). Statins have been around for about 40 years, so we have a fair amount of information about their safety and short and long term effectiveness.
Ezetimibe (Zetia) is another type of drug that lowers LDL. Taken as a pill, it lowers cholesterol by inhibiting its absorption in the small intestine. Ezetimibe is primarily used as an add-on to statins to further lower LDL, or on its own in people who cannot tolerate statins. In older adults, ezetimibe alone has been shown to reduce cardiovascular events, but not stroke.
PCSK9 inhibitors are a new class of cholesterol lowering drugs. They work by allowing more LDL receptors to stay in the liver, thereby allowing the liver to sweep more LDL cholesterol out of the bloodstream. PCSK9 inhibitors have been shown to reduce LDL cholesterol by approximately 60%. There are two PCSK9 inhibitors on the market, evolocumab (Repatha) and alirocumab (Praluent), and both must be given by injection every few weeks.
LDL Lowering Therapies: Are They Safe for Seniors?
The clinical benefit of lowering LDL cholesterol in the elderly has been a point of contention, as people aged 75 and older are not usually included in large numbers in clinical trials. Some have even argued that the risks of LDL lowering treatment may outweigh the benefits for older people compared to young adults. But the evidence debunks this myth.
Meta-analyzes and clinical trials indicate that statin use is not associated with an increased risk of muscle damage, cognitive impairment, cancer, or hemorrhagic stroke compared to those who do not use statins, regardless of age. Likewise, in clinical trials, the risk of liver or kidney damage is similar in people taking statins or a placebo, regardless of age. A prospective study Assessment of hepatic safety in the very elderly showed statins to be overall safe in patients 80 years of age and older.
The most common side effect of statins is muscle pain, which occurs in less than 1% of patients. Even though one type of statin causes side effects in a person, another statin may not. Statins can raise blood sugar levels, but this is unlikely to lead to type 2 diabetes in people who are not already at high risk for the disease. Likewise, the use of ezetimibe is largely safe, with diarrhea and upper respiratory tract infections being the most common side effects. Notably, the safety profile of ezetimibe in combination with statins is the same as that of statins alone, even in the elderly. Finally, it has not been shown that PCSK9 inhibitors increase the risk of diabetes, neurocognitive disorders, liver or muscle damage.
Evidence of LDL Lowering Therapies in the Elderly
The question remains: do the benefits of cholesterol-lowering treatments outweigh the risks for the elderly? In one systematic review and meta-analysis Posted in The Lancet, the researchers evaluated the clinical benefit of cholesterol-lowering therapy with a statin and without a statin in the elderly. To do this, they extracted and reanalyzed data from previous studies that had evaluated cholesterol-lowering treatments with statins and without statins. The analysis included 21,492 patients aged 75 years and older. Of these, 54.1% of patients had been enrolled in statin trials; 28.9% in the ezetimibe trials; and 16.4% in the PCSK9 inhibitor trials.
Investigators made these important observations:
- Older patients have a 40% higher risk of major cardiovascular events than younger patients (5.7% vs. 4.1%).
- For every 38 mg / dL reduction in LDL cholesterol, older patients taking LDL-lowering therapies experienced a 26% reduction in the risk of major cardiovascular events.
- Lowering LDL prevented cardiovascular events to a similar degree in older and younger adults.
- In older adults, statin and non-statin lowering LDL therapies have also been shown to be effective in preventing most major cardiovascular events. The exception was stroke, for which treatment without a statin was slightly more effective; this is probably due to the use of PCSK9 inhibitors.
The above analysis largely represented elderly patients with existing cardiovascular disease. Ongoing trials will assess the usefulness of statins in elderly patients as a primary prevention of major cardiovascular events.
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The post office Lowering cholesterol protects your heart and brain, regardless of your age appeared first on Harvard Health Blog.
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