How to Prevent Pharmacological Overtreating in the Elderly

Cardiovascular risk increases dramatically with over the years, which almost inevitable leads to treating the elderly with statins, based on risk. To prevent over treatment, we need to identify fragile patients (bed-ridden or with dementia), whose condition might make this treatment futile on the one hand, and on the other hand, patients who regardless their age are at low risk, and therefore do not need this kind of treatment, despite what scores might say.

This study focused on finding “negative” factors, that is, those which might highlight age-based risk, in order to identify the elderly patients at short-term low coronary or cardiovascular risk.

The study looked at 5805 patients (mean age 69, followed up at 2.7 years) 13 candidate “negative” markers were evaluated (coronary artery calcium = 0, coronary artery calcium ≥10, no carotid plaque, no family history, normal ankle/arm index, test result <25th percentile of the following: carotid intima-media thickness, apolipoprotein B, galectin-3, high-sensitivity C-reactive protein, lipoprotein(a), N-terminal pro–B-type natriuretic peptide and transferrin; and apolipoprotein A1 >75th.

Coronary artery calcium = 0 and coronary artery calcium ≤10 were the strongest negative risk markers, with 80% lower risk than expected from traditional risk factor assessment, followed by galectin-3 and absence of carotid plaque as factors capable or “subtracting” risk.

Read also: Though Systolic BP Seems More Important, Diastolic BP Should Not Be Disregarded.

The rest of markers had a less impressive impact.

Risk reclassification across the Class I statin-eligibility threshold defined by the AHA/ACC was by far for coronary artery calcium = 0 (net reclassification index 0.23) and coronary artery calcium ≤10 (reclassification index 0.28), galectin-3 (reclassification index 0.14) and absence of carotid plaque (0.08).

Conclusion

Elderly patients with coronary artery calcium = 0 or ≤10, low galectin-3, or no carotid plaque have low cardiovascular risk (much lower than the traditional scores predict) and challenge the need to treat this population with statins.

Original Title: Negative Risk Markers for Cardiovascular Events in the Elderly.

Reference: Martin Bødtker Mortensen et al. J Am Coll Cardiol 2019;74:1–11.

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