THE ROLE OF CHOLESTEROL MANAGEMENT IN CORONARY DISEASE RISK REDUCTION IN ELDERLY PATIENTS

For many years, coronary heart disease (CHD) was considered to be mainly a disease of middle-aged men. Over the past 2 decades, however, there has been a progressive decline in CHD mortality in middle-aged men, and, increasingly, peak CHD prevalence has shifted to the elderly years. A growing awareness of the magnitude of CHD in older women also exists. This shift in the population distribution of CHD raises new questions about its pathogenesis in the elderly and about prevention and management of the disease in later years. The clinical management of patients with established CHD has improved; advances in the treatment of coronary artery disease and its complications account in part for the decline in age-adjusted mortality for CHD. Effective intervention in the risk factors for coronary disease almost certainly has contributed to the delay in onset of new CHD and has prolonged the lives of many patients with established CHD. Many prospective studies have delineated the impact of coronary risk factors on the middle-aged incidence of CHD, that is, before age 65 years. Fewer studies have examined the role of risk factors in causing CHD in the elderly population. Similarly, most clinical trials designed to test the efficacy of risk factor modification for preventing CHD have included mainly middle-aged men. Despite the favorable outcomes, strong proponents of evidence-based medicine have questioned whether the results of prospective studies and clinical trials that have been limited for the most part to middle-aged men can be extrapolated to the elderly population.24 and 25 Although most investigators concede that intensive risk factor reduction in high-risk, middle-aged men is warranted based on the positive results of clinical trials, many take a more conservative stance regarding risk factor management in older persons. This conservative approach has been widely used in the management of high serum cholesterol; an elevated serum cholesterol has traditionally been the last major risk factor to be accepted as being clinically important. This article examines generic issues related to the benefit of risk factor management in the elderly population. The focus is the efficacy of cholesterol-lowering therapies in older people. A general approach to controlling high serum cholesterol is provided by the National Cholesterol Education Program (NCEP). The clinical strategy of NCEP is described in its second Adult Treatment Panel (ATP II) report.20 and 21 This report recognizes the growing importance of CHD in the elderly population and places increased emphasis on the management of high serum cholesterol in women and the elderly. ATP II contends that principles of cholesterol management delineated for younger and middle-aged persons largely can be extended to the elderly population. The report nonetheless emphasizes that clinical management in older persons must be tempered with sound clinical judgment and common sense. Older patients often have multiple medical problems, thus several factors must be taken into account and balanced when making decisions about particular therapies. In the discussion to follow, these various factors are considered in some detail in an attempt to spell out a reasonable approach to the management of high serum cholesterol in older persons.