High or abnormal cholesterol levels, inflammation and endothelial dysfunction play a major role in atherosclerosis and plaque buildup, which is the most common cause of heart attacks and strokes. (An endothelial dysfunction refers to a malfunction of the inner lining of the blood vessels on the surface of the heart. It results in these vessels inappropriately narrowing instead of widening, restricting blood flow.) There are many different types of cholesterol, including high-density lipoprotein (HDLP). HDL), or the good cholesterol); Triglyceride (A by-product of the consumed excess calories, which are stored as fat); And low-density lipoprotein (LDL, or bad cholesterol).
It has been well-proven that lowering bad cholesterol, sometimes regardless of whether or not you have high cholesterol, improves cardiovascular outcomes. But do older people reap the same benefits from lowering cholesterol, and do they face additional risks?
Lowering low-density lipoprotein reduces the risk of cardiovascular disease
Studies have consistently shown that lowering LDL cholesterol reduces the risk of cardiovascular death, heart attacks, strokes, and the need for cardiac catheterization or bypass operations. This has been seen in patients with coronary artery disease, as well as in high-risk patients without coronary artery disease.
Lifestyle changes can reduce cholesterol by about 5% to 10%, while cholesterol-lowering medications can reduce LDL cholesterol by 50% or more. So, while lifestyle modifications such as eating a heart-healthy diet (the Mediterranean diet, for example), quitting smoking, getting regular exercise, and losing weight are necessary to reduce the risk of developing cardiovascular disease, it often Medicines are needed to provide additional protection for the heart and blood vessels.
Statins, including atorvastatin (Lipitor), simvastatin (Zocor), rosuvastatin (Crestor), and pravastatin (Pravachol), are the mainstay of treatment for lowering LDL. Statins work by reducing the body’s production of cholesterol, which promotes the liver’s circulating absorption of LDL into the blood. But not all of the benefits of statins can be explained by lowering LDL alone. Studies show Statins have positive 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 great deal of information about their safety and effectiveness in the short and long term.
Ezetimibe (Zetia) is a different type of LDL lowering drug. When taken as a pill, it lowers cholesterol by inhibiting its absorption in the small intestine. Ezetimibe is primarily used as a statin supplement to achieve further LDL reduction, or on its own in people who cannot tolerate statins. In older adults, ezetimibe alone has been found to reduce cardiovascular events but not stroke.
PCSK9 inhibitors are a new class of cholesterol-lowering drugs. It works by allowing more low-density lipoprotein receptors to remain in the liver, allowing the liver to eject more harmful cholesterol from the bloodstream. PCSK9 inhibitors have been shown to reduce LDL cholesterol by approximately 60%. There are two types of PCSK9 inhibitors on the market, evolocumab (Repatha) and alirocumab (Praluent), and they need to be taken by injection every few weeks.
LDL Lowering Treatments: Are They Safe for Older People?
The clinical benefit of lowering LDL cholesterol in the elderly has been a point of contention, because people 75 years of age or older are not usually included in large numbers in clinical trials. Some have even argued that the risks of LDL-lowering therapy may outweigh the benefits for the elderly compared to younger 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 injury, cognitive impairment, cancer, or hemorrhagic stroke compared with those who did not use statins, regardless of age. Likewise, in clinical trials, the risk of liver or kidney injury is similar in people who take statins or placebo, regardless of age. a Prospective study The evaluation of liver safety in very elderly patients found statins to be generally safe in patients 80 years of age or older.
The most common side effect of statins is muscle pain, which occurs in less than 1% of patients. Even if a type of statin causes side effects in a person, it may not. Statins can raise blood sugar, but this is unlikely to lead to type 2 diabetes in anyone who is not already at risk of developing the condition. Likewise, ezetimibe is largely safe to use, with diarrhea and upper respiratory infections being the most common side effects. Notably, the safety profile for ezetimibe plus statins is the same as for statins alone, even in the elderly. Finally, PCSK9 inhibitors have not been found to increase the risk of diabetes, neurocognitive disorders, liver injury, or muscle injury.
Evidence for low-density lipoprotein-lowering therapies in the elderly
The question remains: Do the benefits of cholesterol-lowering treatments outweigh the risks to the elderly? at Systematic review and meta-analysis Posted in The scalpelIn the elderly, researchers evaluated the clinical benefit of statin and non-statin cholesterol-lowering therapy. They did this by extracting and re-analyzing data from previous studies that evaluated statin and non-statin cholesterol-lowering treatments. The analysis included 21,492 patients aged 75 years and over. Of these, 54.1% were enrolled in statin trials. 28.9% in the ezetimibe trials; And 16.4% in trials of PCSK9 inhibitors.
The investigators made these important observations:
- Older patients have a 40% risk of major cardiovascular events compared to younger patients (5.7% versus 4.1%).
- For every 38 mg / dL reduction in LDL cholesterol, older patients taking low-density lipoprotein lowering therapies had a 26% reduction in the risk of major cardiovascular disease.
- Lowering LDL prevented cardiovascular events to a similar degree in the elderly and young adults.
- In the elderly, LDL-lowering treatments and statins were similarly ineffective in preventing most major cardiovascular events. The exception was stroke, as treatment without the statins was slightly more effective. This is likely due to the use of PCSK9 inhibitors.
The analysis above is largely representative of older patients with existing cardiovascular disease. There are ongoing trials that will help evaluate the utility of statins in older patients as a primary prevention of major cardiovascular events.
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