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      Association of Statin Use With All-Cause and Cardiovascular Mortality in US Veterans 75 Years and Older

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          Abstract

          Among US veterans 75 years and older and free of atherosclerotic cardiovascular disease at baseline, is statin use associated with lower risk of mortality? In this retrospective cohort study that used propensity score overlap weighting and included 326 981 participants, statin use, compared with no statin use, was significantly associated with a lower risk of all-cause and cardiovascular mortality (hazard ratios, 0.75 and 0.80, respectively). Among older US veterans without atherosclerotic cardiovascular disease at baseline, statin therapy was significantly associated with a lower risk of mortality. Data are limited regarding statin therapy for primary prevention of atherosclerotic cardiovascular disease (ASCVD) in adults 75 years and older. To evaluate the role of statin use for mortality and primary prevention of ASCVD in veterans 75 years and older. Retrospective cohort study that used Veterans Health Administration (VHA) data on adults 75 years and older, free of ASCVD, and with a clinical visit in 2002-2012. Follow-up continued through December 31, 2016. All data were linked to Medicare and Medicaid claims and pharmaceutical data. A new-user design was used, excluding those with any prior statin use. Cox proportional hazards models were fit to evaluate the association of statin use with outcomes. Analyses were conducted using propensity score overlap weighting to balance baseline characteristics. Any new statin prescription. The primary outcomes were all-cause and cardiovascular mortality. Secondary outcomes included a composite of ASCVD events (myocardial infarction, ischemic stroke, and revascularization with coronary artery bypass graft surgery or percutaneous coronary intervention). Of 326 981 eligible veterans (mean [SD] age, 81.1 [4.1] years; 97% men; 91% white), 57 178 (17.5%) newly initiated statins during the study period. During a mean follow-up of 6.8 (SD, 3.9) years, a total 206 902 deaths occurred including 53 296 cardiovascular deaths, with 78.7 and 98.2 total deaths/1000 person-years among statin users and nonusers, respectively (weighted incidence rate difference [IRD]/1000 person-years, –19.5 [95% CI, –20.4 to –18.5]). There were 22.6 and 25.7 cardiovascular deaths per 1000 person-years among statin users and nonusers, respectively (weighted IRD/1000 person-years, –3.1 [95 CI, –3.6 to –2.6]). For the composite ASCVD outcome there were 123 379 events, with 66.3 and 70.4 events/1000 person-years among statin users and nonusers, respectively (weighted IRD/1000 person-years, –4.1 [95% CI, –5.1 to –3.0]). After propensity score overlap weighting was applied, the hazard ratio was 0.75 (95% CI, 0.74-0.76) for all-cause mortality, 0.80 (95% CI, 0.78-0.81) for cardiovascular mortality, and 0.92 (95% CI, 0.91-0.94) for a composite of ASCVD events when comparing statin users with nonusers. Among US veterans 75 years and older and free of ASCVD at baseline, new statin use was significantly associated with a lower risk of all-cause and cardiovascular mortality. Further research, including from randomized clinical trials, is needed to more definitively determine the role of statin therapy in older adults for primary prevention of ASCVD. This retrospective cohort study uses Veterans Health Administration data on adults free of atherosclerotic cardiovascular disease (ASCVD) to evaluate the association between new statin use and all-cause and cardiovascular mortality, and a composite of ASCVD events (myocardial infarction, ischemic stroke, and revascularization with CABG surgery or PCI), in veterans 75 years and older.

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          The burden of cardiovascular disease in the elderly: morbidity, mortality, and costs.

          Cardiovascular disease (CVD) in older Americans imposes a huge burden in mortality, morbidity, disability, functional decline, and health care costs. In light of the projected growth of the population of older adults over the next several decades, the societal burden attributable to CVD will continue to rise. There is thus an enormous opportunity to foster successful aging and to increase functional life years through expanded efforts aimed at CVD prevention. This article provides an overview of the epidemiology of CVD in older adults, including an assessment of the impact of CVD on mortality, morbidity, and health care costs.
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            Safety and benefit of discontinuing statin therapy in the setting of advanced, life-limiting illness: a randomized clinical trial.

            For patients with limited prognosis, some medication risks may outweigh the benefits, particularly when benefits take years to accrue; statins are one example. Data are lacking regarding the risks and benefits of discontinuing statin therapy for patients with limited life expectancy.
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              Statins for primary prevention of cardiovascular events and mortality in old and very old adults with and without type 2 diabetes: retrospective cohort study

              Abstract Objective To assess whether statin treatment is associated with a reduction in atherosclerotic cardiovascular disease (CVD) and mortality in old and very old adults with and without diabetes. Design Retrospective cohort study. Setting Database of the Catalan primary care system (SIDIAP), Spain, 2006-15. Participants 46 864 people aged 75 years or more without clinically recognised atherosclerotic CVD. Participants were stratified by presence of type 2 diabetes mellitus and as statin non-users or new users. Main outcome measures Incidences of atherosclerotic CVD and all cause mortality compared using Cox proportional hazards modelling, adjusted by the propensity score of statin treatment. The relation of age with the effect of statins was assessed using both a categorical approach, stratifying the analysis by old (75-84 years) and very old (≥85 years) age groups, and a continuous analysis, using an additive Cox proportional hazard model. Results The cohort included 46 864 participants (mean age 77 years; 63% women; median follow-up 5.6 years). In participants without diabetes, the hazard ratios for statin use in 75-84 year olds were 0.94 (95% confidence interval 0.86 to 1.04) for atherosclerotic CVD and 0.98 (0.91 to 1.05) for all cause mortality, and in those aged 85 and older were 0.93 (0.82 to 1.06) and 0.97 (0.90 to 1.05), respectively. In participants with diabetes, the hazard ratio of statin use in 75-84 year olds was 0.76 (0.65 to 0.89) for atherosclerotic CVD and 0.84 (0.75 to 0.94) for all cause mortality, and in those aged 85 and older were 0.82 (0.53 to 1.26) and 1.05 (0.86 to 1.28), respectively. Similarly, effect analysis of age in a continuous scale, using splines, corroborated the lack of beneficial statins effect for atherosclerotic CVD and all cause mortality in participants without diabetes older than 74 years. In participants with diabetes, statins showed a protective effect against atherosclerotic CVD and all cause mortality; this effect was substantially reduced beyond the age of 85 years and disappeared in nonagenarians. Conclusions In participants older than 74 years without type 2 diabetes, statin treatment was not associated with a reduction in atherosclerotic CVD or in all cause mortality, even when the incidence of atherosclerotic CVD was statistically significantly higher than the risk thresholds proposed for statin use. In the presence of diabetes, statin use was statistically significantly associated with reductions in the incidence of atherosclerotic CVD and in all cause mortality. This effect decreased after age 85 years and disappeared in nonagenarians.
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                Author and article information

                Journal
                JAMA
                JAMA
                American Medical Association (AMA)
                0098-7484
                July 07 2020
                July 07 2020
                : 324
                : 1
                : 68
                Affiliations
                [1 ]New England Geriatric Research, Education, and Clinical Center (GRECC), VA Boston Healthcare System, Boston, Massachusetts
                [2 ]Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, Massachusetts
                [3 ]Division of Aging, Brigham & Women’s Hospital, Harvard Medical School, Boston, Massachusetts
                [4 ]Department of Medicine, Brigham & Women’s Hospital, Harvard Medical School, Boston, Massachusetts
                [5 ]Section of Geriatric Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
                [6 ]Geriatric Research, Education, and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
                [7 ]Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
                [8 ]Atlanta VA Medical Center, Decatur, Georgia
                [9 ]Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
                [10 ]Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
                Article
                10.1001/jama.2020.7848
                7341181
                32633800
                d1fc4aff-2568-405b-8c34-199b2c18b473
                © 2020
                History

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