Statins reduce mortality in over 75s – even if no signs of plaque

Statins play a well-established role in secondary prevention for patients with proven cardiovascular atherosclerotic disease.
 
However, their use as a primary prevention measure remains controversial.
 
Now, new research published in JAMA Network has found statins may be beneficial in that role.
 
The observational study of more than 300,000 American veterans compared statin use with no statin use among patients aged 75 and older who had no signs of atherosclerotic cardiovascular disease.
 
It found statin use was significantly associated with a lower risk of all-cause and cardiovascular mortality.
 
During a mean follow-up of 6.8 years, there were 22.6 cardiovascular deaths per 1000 person-years among statin users, compared to 25.7 among non-users.
 
Meanwhile, there were 66.3 events per 1000 person-years among statin users, compared to 70.4 events for those not on a statin.
 
Interventional cardiologist Dion Stub is a medical advisor to Ambulance Victoria and associate professor at Monash University.
 
He told newsGP this study adds further weight to arguments in favour of considering statins as a primary preventive measure.
 
‘There’s essentially no debate regarding the benefit of statins in secondary prevention,’ Associate Professor Stub said. ‘We know statins are a life-saving drug as secondary prevention for those who have proven cardiovascular atherosclerotic disease, either coronary disease, peripheral vascular disease or stroke.
 
‘Statins are beyond question one of the best medications we have to reduce further events and reduce cardiovascular mortality.’
 
But he says their role in primary prevention is currently controversial, as there is currently ‘much less’ evidence regarding their effectiveness in this context.
 
‘Where the controversy with statins lies is, because they are so good at secondary prevention, [the question remains] would they be useful at preventing events as primary prevention in people who have no history of cardiovascular disease?’ he said.
 
In fact, Associate Professor Stub says, their use as a primary prevention strategy has been questioned in the past, with ‘sensational’ reports often implying clinicians who prescribe statins in the absence of established disease may be ‘in cahoots’ with pharmaceutical companies.
 
But Associate Professor Stub has long believed statins may play a crucial role in primary prevention and said additional, preferably randomised, studies are needed to explore this issue further.
 
One example of the ‘significant, growing evidence’ that statins may help prevent cardiovascular events, according to Associate Professor Stub, can be found in the ASPREE (Aspirin in Reducing Events in the Elderly) study.
 
While that trial showed no significant benefit to aspirin as a primary preventive measure, he says a sub-study has now been performed on the same population looking at patients who were on statins.
 
‘It didn’t show a mortality benefit, but it showed a significant reduction in acute myocardial infarct (AMI),’ he said.
 
Associate Professor Stub says more information will be gathered on the role of statins in primary prevention when the Australian STAREE (Statins in Reducing Events in the Elderly) trial concludes.
 
In the meantime, he believes the results of this new paper are very encouraging, and that they may inform future care.
 
‘Even at the older age of 75 and above, when we may think the benefits may be less, this trial showed … there may be significant benefit to starting older patients without proven cardiovascular disease on statins,’ Associate Professor Stub said.
 
Consequently, he wonders if statins may be potentially even more beneficial in younger patients who do not yet have established plaque and negative remodelling in their arteries.
 
‘As a clinician, it’s very clear that statins are the best tool we have to stabilise plaques and potentially prevent AMI,’ he said.
 
‘So they may even be better to be started earlier, but that remains to be proven.’
 
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ASPREE trial atherosclerosis cardiovascular disease cholesterol mortality STAREE trial statins