Should we reconsider the role of age in treatment allocation for primary prevention of cardiovascular disease?

Abstract

Clinical practice guidelines for primary prevention of cardiovascular disease (CVD) are centred on a high-risk approach. The current role of cardiovascular risk assessment in clinical practice is two-fold. First, it serves as a starting point for risk communication between physicians and patients. Secondly, it is used as the primary mode to select candidates for lipid-lowering treatment (see Supplementary material online, Figures S1–S3 ).1–3 Based on an individual's age and risk factor profile, CVD risk calculators provide clinicians with an estimate of the individual's probability for developing CVD in the coming 10 years.4–6 Since CVD is highly age related, age is the strongest predictor for CVD in such calculators. In the most recent revisions of American and British prevention guidelines, risk thresholds for initiation of pharmacological treatment to reduce low-density lipoprotein (LDL) cholesterol have been substantially lowered. This decision has been driven by the accumulating data on the efficacy7,8 and safety profile9,10 of statins in primary prevention, as well as the low costs of generic statins. However, by lowering the thresholds, otherwise healthy older adults with minimal or no risk factors are now considered candidates for statin treatment solely by virtue of their age. Doctors are recommended to discuss statin initiation with men who have optimal risk factor levels at an age between 63 and 66 in the USA or UK ( Table 1 ). For women this is the case around the age of 70. As a consequence, the vast majority of individuals aged 55–65 and almost everyone aged ≥65 in the general population is currently considered a candidate for statin treatment in both the …