Review: statins reduce all-cause mortality in elderly patients with coronary heart disease.

Question In elderly patients with coronary heart disease (CHD), do statins reduce all-cause mortality? Methods Data sources MEDLINE, EMBASE/Excerpta Medica, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, and ACP Journal Club (all to 2007); conference abstracts; reference lists; and unpublished data from investigators. Study selection and assessment Randomized controlled trials (RCTs) in any language that compared statins with placebo in 50 patients 65 years of age with documented CHD at randomization and evaluated all-cause mortality, CHD mortality, nonfatal myocardial infarction (MI), revascularization, or stroke at 6 months of follow-up. 9 RCTs (n =19569, age range 65 to 82 y) met the selection criteria. Outcomes All-cause mortality, CHD mortality, nonfatal MI, revascularization, and stroke. Main results Meta-analysis showed that statins reduced all-cause mortality, CHD mortality, nonfatal MI, revascularization, and stroke compared with placebo (Table). Conclusion Statins reduce all-cause mortality in elderly patients with coronary heart disease. Statins vs placebo in elderly patients with coronary heart disease (CHD)* Outcomes at 5 y Number of trials (n) Weighted event rates RRR (95% CI) NNT (CI) Statins Placebo All-cause mortality 9 (19569) 15% 19% 22% (11 to 35) 28 (15 to 56) CHD mortality 9 (19569) 7.9% 11% 30% (17 to 47) 34 (18 to 69) Nonfatal MI 8 (8872) 7.8% 11% 26% (11 to 40) 38 (16 to 118) Revascularization 7 (8506) 9.7% 14% 30% (17 to 47) 24 (12 to 59) Stroke 5 (17421) 5.3% 7.0% 25% (6 to 44) 58 (27 to 177) *MI = myocardial infarction; other abbreviations defined in Glossary. Weighted event rates, RRR, and CI calculated from control event rates and relative risks in article. NNT and CI provided in article; based on Bayesian posterior estimates. Commentary The well-done meta-analysis by Afilalo and colleagues shows that statins reduce all-cause and CHD mortality in elderly patients with established CHD. Trials are inconsistent on the benefit of statins for either primary or secondary prevention of CHD in the elderly, highlighting the usefulness of this review. As a result of such variability, many clinicians are justifiably wary of using statins in elderly persons, many of whom are already taking many other medications. The review provides clear evidence that persons who are >65 years of age who have CHD benefit from statin therapy, and the risks associated with additional medications and potential interactions are justified. The main caveat of this meta-analysis is that most trials showed benefit for statins in lowering low-density lipoprotein (LDL) cholesterol levels in the range of 25% to 30% from baseline. The statins used were simvastatin, fluvastatin, and pravastatin. Thus, recommendations for more aggressive lowering of LDL cholesterol levels still may not apply to those >65 years of age. Subgroup analysis of the Treating to New Targets trial, which compared atorvastatin doses of 80 mg and 10 mg, failed to show a benefit for all-cause mortality, although a benefit was found for cardiovascular mortality (1).