Editorial for “Managing Hypercholesterolemia in Adults Older Than 75 Years Without a History of Atherosclerotic Cardiovascular Disease. An Expert Clinical Consensus From the National Lipid Association and American Geriatrics Society”

Abstract

Since the first statin was approved by the Food and Drug Administration in 1987, low-density lipoprotein cholesterol (LDL-C)-lowering drugs have been some of the most highly prescribed drugs in the US. In 2018, 25.2 million Medicare beneficiaries were taking LDL-C-lowering therapies, with the associated Medicare expenditure at $3.3 billion [1]. Randomized controlled trials of statin therapy demonstrate reductions in atherosclerotic cardiovascular disease (ASCVD) in a broad population of individuals ranging from intermediate risk to very high risk individuals in both primary and secondary prevention and across a broad range of baseline low-density lipoprotein cholesterol levels [2].

However, the management of hypercholesterolemia in adults over 75 years of age presents unique challenges, particularly in the absence of established ASCVD. The Expert Clinical Consensus statement, a collaborative effort from the National Lipid Association (NLA) and the American Geriatrics Society (AGS), addresses these complexities by combining expertise from leading professionals in clinical lipidology, geriatrics, cardiology, and pharmacology [3]. The NLA, a prominent authority on lipid and cardiovascular health, and the AGS, an organization dedicated to improving the health and quality of life for older adults, have aligned their efforts to ensure that lipid management for adults over 75 years of age is personalized, evidence-based, and mindful of the diverse needs of our aging population.

This consensus is of significant importance to clinicians involved in the care of older adults, as it provides evidence-based guidance tailored specifically to those over 75 years without ASCVD. Such patients face unique physiological and clinical considerations, including frailty, comorbidities, and varying life expectancies. Given the paucity of randomized controlled trials specifically in adults over 75 years without ASCVD [4], assessment of cardiovascular risk and treatment of hypercholesterolemia may not be straightforward for clinicians. This consensus document emphasizes a patient-centered approach, weighing the benefits of lipid-lowering therapies against possible adverse effects and aligning treatment decisions with individual patient goals and values.

Clinicians will find practical insights on assessing ASCVD risk in older adults, incorporating tools like coronary artery calcium (CAC) scoring to refine treatment decisions. Consistent with the principles outlined by the AGS for managing older adults with multimorbidity, the document stresses the importance of considering patients' individual preferences, comorbidities, and overall life context in guiding treatment [5]. Recommendations focus mostly on the initiation of statins, given less evidence for non-statin lipid lowering options in this population, along with monitoring for potential statin-associated risks and consideration for deprescribing in cases of limited life expectancy. Through its thoughtful synthesis of current evidence, the paper equips clinicians with strategies to support effective, compassionate lipid management for aging adults, enhancing their quality of life and long-term health outcomes.

All authors contributed to the study concept and design, as well as the preparation of the manuscript.

V.B. received research support from Amgen, DalCor, Esperion, Novartis, Sanofi, and from the National Institute on Aging via subcontract from Atrium Health/Wake Forest University; is a data safety monitoring board member for Eli Lilly and Verve Therapeutics; and attended an advisory board for New Amsterdam Pharma. S.A.L. declares no conflicts of interest.

This publication is linked to a related article by Bittner et al. To view this article, visit https://doi.org/10.1111/jgs.19398.