Stroke and CVD Prevention With Lipid Lowering Drugs
Stroke and CVD Prevention With Lipid Lowering Drugs
Objective To determine the association between use of lipid lowering drugs (statin or fibrate) in older people with no known history of vascular events and long term risk of coronary heart disease and stroke
Design Ongoing prospective population based cohort study recruited in 1999–2000, with five face-to-face examinations.
Setting Random sample of community dwelling population aged 65 years and over, living in three French cities (Bordeaux, Dijon, Montpellier).
Participants 7484 men and women (63%) with mean age 73.9 years and no known history of vascular events at entry. Mean follow-up was 9.1 years.
Main outcome measures Adjusted hazard ratios of coronary heart disease and stroke in baseline lipid lowering drug users compared with non-users, calculated using multivariable Cox proportional hazard models adjusted for numerous potential confounding factors. Hazard ratios were estimated for use of any lipid lowering drug and for statin and fibrate separately.
Results Lipid lowering drug users were at decreased risk of stroke compared with non-users (hazard ratio 0.66, 95% confidence interval 0.49 to 0.90); hazard ratios for stroke were similar for statin (0.68, 0.45 to1.01) and fibrate (0.66, 0.44 to 0.98). No association was found between lipid lowering drug use and coronary heart disease (hazard ratio 1.12, 0.90 to 1.40). Analyses stratified by age, sex, body mass index, hypertension, systolic blood pressure, triglyceride concentrations, and propensity score did not show any effect modification by these variables, either for stroke or for coronary heart disease.
Conclusion In a population based cohort of older people with no history of vascular events, use of statins or fibrates was associated with a 30% decrease in the incidence of stroke.
In high income countries, a growing proportion of vascular events occur in the oldest people. According to the French national mortality statistics for 2010, people aged 85 years and over accounted for 43% of deaths from coronary heart disease and 49% of deaths from stroke. In contrast, participants in most randomised controlled trials testing cardiovascular drugs are predominantly under the age of 70 years. Therefore, the benefit of these drugs in the oldest people remains uncertain. Randomised trials support the use of hydroxymethyl glutaryl coenzyme A reductase inhibitors (statins) for reducing the incidence of major cardiovascular and cerebrovascular events in people with a history of cardiovascular disease, including those aged 65 years and over. However, evidence of the benefit of statin treatment for primary prevention is limited, especially in older people. Regarding fibrates, the other main class of lipid lowering drugs, very few trials support their efficacy for the primary prevention of cardiovascular events.
New guidelines about cholesterol management based on evidence from randomised controlled trials do not recommend statin treatment in people over 75 years of age without clinical atherosclerotic disease, whereas, in real life, statins are commonly prescribed to older people without clinical evidence of atherosclerosis. Avoiding chronic use of unnecessary drugs is important in older people, who often take many drugs and are at high risk of adverse effects. Because of the limited trial based data on the effect of lipid lowering drugs for primary prevention of vascular events in older people, observational studies in this age group can be valuable. We aimed to study the association between use of lipid lowering drugs and the risk of incident cardiovascular events in a cohort study of 7484 community living people aged 65 years or over at entry with a mean follow-up of nine years.
Abstract and Introduction
Abstract
Objective To determine the association between use of lipid lowering drugs (statin or fibrate) in older people with no known history of vascular events and long term risk of coronary heart disease and stroke
Design Ongoing prospective population based cohort study recruited in 1999–2000, with five face-to-face examinations.
Setting Random sample of community dwelling population aged 65 years and over, living in three French cities (Bordeaux, Dijon, Montpellier).
Participants 7484 men and women (63%) with mean age 73.9 years and no known history of vascular events at entry. Mean follow-up was 9.1 years.
Main outcome measures Adjusted hazard ratios of coronary heart disease and stroke in baseline lipid lowering drug users compared with non-users, calculated using multivariable Cox proportional hazard models adjusted for numerous potential confounding factors. Hazard ratios were estimated for use of any lipid lowering drug and for statin and fibrate separately.
Results Lipid lowering drug users were at decreased risk of stroke compared with non-users (hazard ratio 0.66, 95% confidence interval 0.49 to 0.90); hazard ratios for stroke were similar for statin (0.68, 0.45 to1.01) and fibrate (0.66, 0.44 to 0.98). No association was found between lipid lowering drug use and coronary heart disease (hazard ratio 1.12, 0.90 to 1.40). Analyses stratified by age, sex, body mass index, hypertension, systolic blood pressure, triglyceride concentrations, and propensity score did not show any effect modification by these variables, either for stroke or for coronary heart disease.
Conclusion In a population based cohort of older people with no history of vascular events, use of statins or fibrates was associated with a 30% decrease in the incidence of stroke.
Introduction
In high income countries, a growing proportion of vascular events occur in the oldest people. According to the French national mortality statistics for 2010, people aged 85 years and over accounted for 43% of deaths from coronary heart disease and 49% of deaths from stroke. In contrast, participants in most randomised controlled trials testing cardiovascular drugs are predominantly under the age of 70 years. Therefore, the benefit of these drugs in the oldest people remains uncertain. Randomised trials support the use of hydroxymethyl glutaryl coenzyme A reductase inhibitors (statins) for reducing the incidence of major cardiovascular and cerebrovascular events in people with a history of cardiovascular disease, including those aged 65 years and over. However, evidence of the benefit of statin treatment for primary prevention is limited, especially in older people. Regarding fibrates, the other main class of lipid lowering drugs, very few trials support their efficacy for the primary prevention of cardiovascular events.
New guidelines about cholesterol management based on evidence from randomised controlled trials do not recommend statin treatment in people over 75 years of age without clinical atherosclerotic disease, whereas, in real life, statins are commonly prescribed to older people without clinical evidence of atherosclerosis. Avoiding chronic use of unnecessary drugs is important in older people, who often take many drugs and are at high risk of adverse effects. Because of the limited trial based data on the effect of lipid lowering drugs for primary prevention of vascular events in older people, observational studies in this age group can be valuable. We aimed to study the association between use of lipid lowering drugs and the risk of incident cardiovascular events in a cohort study of 7484 community living people aged 65 years or over at entry with a mean follow-up of nine years.
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