Approximately 80 percent of all dea...

Approximately 80 percent of all deaths from coronary heart disease (CHD) happen in persons older than 65 years, and CHD is the leading cause of death in this age assemblage At least 25 percent of men and 42 percent of women in this age arrange have serum total cholesterol evens above 240 mg per dL Nevertheless, the association between elevated cholesterol of the same heights and CHD is not as robust in elderly persons as in younger adults, and the benefits of reducing cholesterol on a levels have not been clearly demonstrated in older patients. Dalal and Robbins reviewed the evidence of benefit from lipid-lowering therapy in somewhat old patients.

They reviewed data from four secondary prevention trials that included significant numbers of [i]role[/i]s older than 65 years. The Scandinavian Simvastatin Survival subject of attention followed more than 1,000 patients for six years and reported a 33 percent reduction in all-cause mortality, a 42 percent reduction in CHD mortality, and a 33 percent reduction in major coronary conclusions in the treated group. The absolute risk reduction was 62 percent and an estimated 10 CHD-related deaths and 17 major cardiac marked occurrences were prevented per 1,000 patient-years of treatment. Similar outcomes were reported from the Cholesterol and returning Events trial, which followed 1283 patients with established CHD who were treated with pravastatin for five years, and from the Long-term Intervention with Pravastatin in Ischemic Disease (LIPID) trial, which followed 3514 patients for six years.

From these studies and the Veterans Affairs studious mood of men with established CHD and continuing risk factors, the authors close that in patients older than 65 secondary prevention of CHD with lipid-lowering medications is effective and does not increase mortality or cause significant adverse circumstances They recommend statins as first-line therapy, with bile acid sequestrants as alternatives unles triglycerides are elevated (see the accompanying table upon page 1998). The evidence of benefit from medicine therapy is less clear in patients older than 75 In these patients, overall general health and comorbid conditions must be considered.

For primary prevention in older patients, the National Cholesterol Education Program praises lifestyle changes as first-line therapy because of unknown effectiveness and touchs about side effects of lipid-lowering medications. sum of two units large studies of primary prevention that included significant numbers of somewhat old patients concluded that primary prevention benefitted older patients. The West of Scotland Coronary Prevention thought of pravastatin included 3,370 men older than 55 After five years, treatment was associated with a 22 percent reduction in total mortality and a 31 percent reduction in coronary consequences The rate of first major coronary marked occurrences also was decreased (by 37 percent after 52 years of follow-up) in the Air Force/Texas Coronary Atherosclerosis Prevention inquiry that examined lovastatin therapy for primary prevention in 1416 patients age 65 to 73 In these and smaller studies, medication has effectively provided primary prevention for CHD without causing significant adverse events

The authors close that lipid-lowering therapy should be considered for patients age 65 to 75 years who have a history of CHD or a moderate to high risk for CHD In patients older than 75 decisions should be made for each individual based in succession life expectancy, comorbidities, and other concerns

ANNE D WALLING, MD

Dalal D Robbins JA. Management of hyperlipidemia in the somewhat old population: an evidence-based approach. southerly Med J November 2002;95:1255-61.

EDITOR'S NOTE: Although these be deriveds are encouraging, they do not mean that we should avoid taking a comprehensive approach to preventing coronary (and other) diseases in older patients. We ne to address smoking, exercise, nutrition, and stres reduction in these patients, as well as the "medical" tasks of screening and prescribing. Many somewhat advanced in life patients have enormous vitality and live surpassingly active lives, regardless of impressive medical histories. For these patients, the longer I can be a "coach," the better. The unsolvable medical vexed questions will intervene soon enough.--A.D.W.

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