Statins Are Cost-effective in the Elderly

Lifetime treatment with statins is a cost-effective therapy across a wide range of elderly patients with and without cardiovascular disease, according to an analysis published this week in Heart.

Although high-intensity statins were projected to be more cost-effective to reduce the risk of cardiovascular events, lower-intensity statins also achieved most of the benefits of treatment.

“Our study may reduce uncertainty in the minds of doctors and policy makers,” lead investigator Borislava Mihaylova, DPhil (University of Oxford, UK), told TCTMD. “The latest UK guidelines do not say that people over age 75 shouldn’t be treated, but the higher uncertainty in this group is engrained in their minds.”

In the US, the cholesterol guidelines suggest that a moderate-intensity statin might be reasonable in those 75 years and older with LDL-cholesterol levels of 70 to 189 mg/dL, but others make no specific recommendations for older patients given the limited data. The US Preventive Services Task Force, for one, recently stated the evidence is insufficient to assess the relative risks and benefits of statin therapy for primary prevention in those 76 years and older. Guidelines from the European Society of Cardiology and European Atherosclerosis Society also do not have specific recommendations for those ages 75 years and older.

In the elderly, there are lingering questions about treatment because the evidence from the randomized, controlled trials is more limited and less certain, particularly among those without history of previous cardiovascular disease, said Mihaylova. While the treatment effects with statins are consistent with middle-aged populations, “the confidence intervals are quite wide,” she said. “That’s been an issue for the guidelines where evidence in particular groups inform recommendations.”

Several observational studies, including meta-analyses, have shown that lowering LDL cholesterol with statins and other drugs is just as effective in older patients as it is at younger ages. 

Looking Into the Elderly

Earlier this year, the researchers assessed the lifetime effects and cost-effectiveness of standard and high-intensity statins across the United Kingdom. That study, which was published in the Lancet, found statins cost-effective across numerous patient categories, with the higher-intensity statins more cost-effective in patients with higher CVD risk and higher LDL-cholesterol levels.

The new analysis assessed the cost-effectiveness of statins in adults 70 years and older enrolled in the UK Biobank and Whitehall II cohort studies. To do so, investigators ran a CVD microsimulation model developed by their group that includes individual participant-level data from large statin trials to project the first occurrence of MI, stroke, coronary revascularization, vascular death, incident diabetes, incident cancer, and nonvascular death.

Data from the Cholesterol Treatment Trialists’ Collaboration was used to model the relative risk reduction in clinical events with each 1-mmol/L reduction in LDL cholesterol.

In total, 15,019 participants without CVD (mean age 72.5 years; 52% male) and 5,103 with CVD (mean age 72.9 years; 66% male) were included in the analysis. The CVD microsimulation model was validated in the UK Biobank and Whitehall II cohorts, with the projected rates of CVD and nonvascular events corresponding to the observed rates.

Across different categories stratified by sex, prior CVD, and LDL cholesterol, statin therapy was estimated to increase individual survival by 0.37 to 1.05 years (0.24 to 0.70 quality-adjusted life-years [QALYs]). High-intensity statin therapy upped that by 0.08 to 0.21 years QALYs (0.04 to 0.18 QALYs). The incremental cost per QALY with statin therapy compared with not taking statins ranged from £116 to £3,502 (approximately $150 to $4,564 USD). For higher-intensity statins, the incremental cost per QALY with statin therapy was £2,213 to £11,778 ($2,884 to $15,349 USD).

In a model designed to reflect uncertainty in event reduction, quality of life, and healthcare costs, there was a high probability that higher-intensity statins were cost-effective across all categories of older people using the willingness-to-pay threshold of £20,000/QALY. There was also a high probability that statins were cost-effective when the willingness-to-pay threshold was tightened up to £5,000/QALY. At the lower threshold, though, standard-intensity statins had the highest probability of being cost-effective in women with LDL-cholesterol levels less than 4.1 mmol/L (160 mg/dL) and men with levels less than 3.4 mmol/L (133 mg/dL), with higher-intensity statins cost-effective in the other categories of elderly.

Findings were similar in participants ages 70 to 75 years and those 75 years and older. Several sensitivity analyses confirmed the cost-effectiveness of treatment, including when high-intensity statins were projected to cost five times the current price.

“The majority of people that we included in our data were already at high cardiovascular risk—99% of those without CVD had a 10-year risk of 10% or greater and 88% had a 10-year risk of 15% or greater,” said Mihaylova. “So, here risk is less relevant in guiding decisions. When we looked by age, by men and women, and by LDL-cholesterol level, we found that statins are of good value for all of those groups.”

She said she hopes the new analysis will strengthen physicians’ resolve to treat more older patients, but added that more evidence is coming. There are two ongoing statin trials in elderly participants, both of which should be completed in 2026. STAREE is a primary prevention study with roughly 10,000 people randomized to placebo or atorvastatin 40 mg that is testing whether treatment reduces the risk of disability-free survival and major CVD events. PREVENTABLE is a similar trial with 20,000 participants looking at whether atorvastatin 40 mg lowers the risk of new dementia or reduces disability (cardiovascular mortality is a secondary outcome).