Implementation of risk-based lipid-lowering therapies in older (age ≥ 65 years) and very-old adults (age ≥ 75 years) with ischemic heart disease in the greater Salzburg region

• Published in: Frontiers in pharmacology Vol. 15; p. 1357334
• Main Authors: Kopp, Kristen, Motloch, Lukas J, Wernly, Bernhard, Berezin, Alexander E, Maringgele, Victoria, Dieplinger, Anna, Hoppe, Uta C, Lichtenauer, Michael
• Format: Journal Article
• Language: English
• Published: Switzerland Frontiers Media S.A 19-06-2024
• Subjects: guidelines; lipid-lowering therapy; low-density lipoprotein cholesterol; older adults; Pharmacology; ST-segment elevation myocardial infarction; very-high risk; older adults; guidelines; lipid-lowering therapy; very-high risk; ST-segment elevation myocardial infarction; low-density lipoprotein cholesterol
• ISSN: 1663-9812; 1663-9812
• DOI: 10.3389/fphar.2024.1357334

European guidelines recommend the implementation of lipid-lowering therapies (LLTs) in adults (≥ 65 years) with established atherosclerotic cardiovascular disease (ASCVD) and for risk-based primary prevention in older adults (≤ 75 years), yet their use in very-old adults (> 75 years) is controversial, discretionary, and oriented on the presence of risk factors. The aim of this retrospective study is to assess guideline-directed LLT implementation and low-density lipoprotein cholesterol (LDL-C) target achievement in high-/very-high-risk older/very-old adults (65-74 and ≥ 75 years) at presentation for ST-segment elevation myocardial infarction (STEMI) and also to assess evidence-based care delivery to older adults in our region.
All STEMI patients with available LDL-C and total cholesterol presenting for treatment at a large tertiary center in Salzburg, Austria, 2018-2020, were screened (
= 910). High-risk/very-high-risk patients (
= 369) were classified according to European guidelines criteria and divided into cohorts by age: < 65 years (
= 152), 65-74 years (
= 104), and ≥ 75 years (
= 113).
Despite being at high-/very-high-risk, prior LLT use was < 40% in the total cohort, with no significant difference by age. Statin monotherapy predominated; 20%-23% of older/very-old adults in the entire cohort were using low-/moderate-intensity stains, 11%-13% were using high-intensity statins, 4% were on ezetimibe therapy, and none were taking proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors. In the secondary prevention cohort, 53% of older/very-old patients used prior LLTs. Significantly higher percentages of older/oldest ASCVD patients (43% and 49%) met LDL-C targets < 70 mg/dL compared to patients < 65 years (29%;
= 0.033), although just 22% and 30% of these older groups attained stricter LDL-C targets of < 55 mg/dL. Low LLT uptake (16%) among older adults aged 64-74 years for primary prevention resulted in 17% and 10% attainment of risk-based LDL-C targets < 70 mg/dL and < 55 mg/dL, respectively. Oldest adults (≥ 75 years) in both primary and secondary prevention groups more often met risk-based targets than older and younger adults, despite predominantly receiving low-/moderate-intensity statin monotherapy.
Secondary prevention was sub-optimal in our region. Less than half of older/very-old adults with established ASCVD met LDL-C targets at the time of STEMI, suggesting severe care-delivery deficits in LLT implementation. Shortcomings in initiation of risk-based LLTs were also observed among high-/very-high-risk primary prevention patients < 75 years, with the achievement of risk-based LDL-C targets in 10%-48% of these patients.