Abstract
Background
Statins are the evidence-based drugs of choice for the prevention of cardiovascular disease (CVD).
Objective
Statin utilization has increased in those ≥65 years, but patterns of utilization in subgroups of elderly are unknown.
Methods
Weighted data from the 2001 through 2006 National Health and Nutrition Examination Surveys were combined for this analysis.
Results
Statin use increased in all sex, age, and risk categories between the 2001-2002 and 2005-2006 surveys, when the highest use was by men aged 65-74 years with CVD (80%), followed by women with CVD aged 65-79 (64-69%), women and men with diabetes aged 65-69 (56 and 94%, respectively); statins were used by <42% of individuals without CVD or diabetes. In adjusted logistic regression models, those with diabetes [odds ratio (OR) 2.1, 95% CI 1.8-2.6], CVD but no diabetes (OR 3.0, 95% CI 2.5-3.6), and CVD and diabetes (OR 5.2, 95% CI 3.9-7.1) were more likely to use statins than those without CVD or diabetes, p=<0.001. A significant interaction between age and gender was found, where 75-79 year old women were more likely to report statin use than men aged 65-69 (OR = 2.07, 95% CI = 1.29, 3.35). In general, those aged 65-69 were more likely to use a statin than those ≥70 (OR 0.57, 95% CI 0.39-1.08, p=0.08). Non-white persons aged ≥70 reported less statin use than whites aged 65-69 (OR=0.17, 95% CI 0.10-0.30). Mexican Americans were less likely to report statin use than whites.
Conclusions
Although statin use has increased substantially over time, statins remain underutilized in both the primary and secondary prevention of CVD in the elderly, with some evidence of disparities by sex, advancing age, and race/ethnicity.
Keywords: Lipids, Statins, Elderly, Prevention, Population, Cardiovascular disease
Although remaining the leading cause of death in the US, cardiovascular disease (CVD) incidence and mortality has fallen by >25% over the past decade, including those >65 years.1 This decline has in large part been attributed to the use of evidence-based prevention medications, including statins .2, 3 Treatment of LDL-C with, has been shown to reduce the risk of both coronary heart disease (CHD) and stroke in secondary prevention populations aged 65 to 80 years. In a prospective meta-analysis of 14 statin trials those over age 65 (n=6446) experienced a 19% reduction in major cardiovascular events, a benefit similar to the 22% reduction in risk experienced by those ≤65 years (n=7902).4 The few data available from primary prevention populations without CVD or diabetes also suggest individuals >70 years benefit from statin therapy.5, 6
A previous analyses of the National Health and Nutrition Examination Surveys (NHANES) found that between the 1999-2000 and 2003-2004 surveys, statin use increased from 32% to 44% in those aged 60-74 , and 28% to 42% by those aged ≥75 years.7 Another analysis of the 2003-2004 survey found that the NCEP ATP III-defined LDL-C goal was achieved by 63% of those aged 60-69, and 55% of those aged 70-79.8 We undertook this analysis to further evaluate lipid levels and the use of statins and in older adults through the 2005-2006 survey, and to evaluate the influence of age, gender, race or ethnicity, and cardiovascular and diabetes status.
Methods
Data from the National Health and Nutrition Examination Survey (NHANES) collected during NHANES 1999-2000, 2001-2002, 2003-2004, 2005-2006 surveys were used in this analysis. NHANES are nationally representative cross-sectional surveys of the U.S. civilian noninstitutionalized population that utilize a stratified multistage probability sample. Procedures are similar for each survey and include a home interview followed by a physical examination in a mobile examination center using standardized techniques and equipment. Approximately half of respondents to the medical history component of the NHANES also had lipid panel, and approximately half of the lipid panels were fasting, further limiting the number of individuals available for analysis. Therefore, to evaluate the statin utilization and lipid levels by age, gender, race/ethnicity and disease status, the 2001-2006 surveys were combined due to the small number of NHANES participants in age, race, and gender subgroups in individual surveys. More specimens were available for non-HDL-C since fasting was not required.
Race-ethnic group based on self-reporting was categorized as non-Hispanic white, non-Hispanic black, Mexican American, other race including multi-racial and other Hispanics. The Mexican American groups were used for comparison in this analysis. Cardiovascular disease was defined as every having been told they had coronary heart disease, angina/angina pectoris, heart attack, or stroke. Diabetes was defined by a doctor having told them they had diabetes, use of diabetes pills or insulin, of fasting blood glucose >125 mg/dL.
Statistical analysis was performed using SAS 9.1 survey procedures. For each survey, weighted data were used to take into account the unequal probabilities of selection resulting from the sample design and from planned oversampling of certain subgroups to obtain a nationally representative sample of income data. Comparisons of prevalence were considered significant if the 95% confidence intervals were exclusive; a p-value of <0.05 considered significant for other comparisons. Chi-square testing and contrasts were used to compare proportions. Logistic regression was used to model predictors of statin use.
Results
In women >65 years, statin use increased from 23% in 2001-2002 to 37% in the 2005-2006 surveys (data not shown). In men >65 years, statin use increased from 25% to 44% over the same time period. In those without CVD or diabetes, statin use peaked at similar levels in the 70-74 age group in men and in the 75-79 age group in women (37-42%) [Table 1]. In women with CVD, statin use remained fairly stable (62-69%) in the 65-69 age group between 2001-2002 and 2005-2006 surveys, but increased from 37-46% to 64-66%in the 70 and 79 age group; statin use also increased in the >80 age group, from 27 to 43%. In men with CVD, in the 2001-2002 survey 60-63% of those aged 65-74 reported statin use, which increased to 80% by the 2005-2006 survey. In men with CVD >75 years, statin use increased from about 33% to 55%. Insufficient numbers of individuals with diabetes without and with CVD were evaluated to permit comparison of the 2 surveys, with a greater number were available for subsequent analyses of the pooled surveys.
Table 1.
Trends in statin use
| No CVD and No Diabetes | No CVD and Diabetes | CVD | ||||
|---|---|---|---|---|---|---|
| Age group (years) | 2001-2002 Statin use, % (95% CI) | 2005-2006 Statin use, % (95% CI) | 2001-2002 Statin use, % (95% CI) | 2005-2006 Statin use, % (95% CI) | 2001-2002 Statin use, % (95% CI) | 2005-2006 Statin use, % (95% CI) |
| WOMEN | ||||||
| 65-69 | 18.3 (9.8, 26.9) | 24.3 (16.7, 31.8) | 29.5 (9.4, 49.6) | 55.8 (43.8, 67.9) | 61.5 (34.4, 88.6) | 68.8 (44.7, 92.9) |
| 70-74 | 16.1 (5.7, 26.4) | 25.9 (12.8, 39.1) | 36.2 (15.1, 57.3) | 39.1 (17.5, 60.6) | 36.9 (17.1, 56.7) | 66.3 (43.6, 88.9) |
| 75-79 | 25.2 (13.3, 37.0) | 41.9 (33.6, 50.2) | 16.6 (7.3, 26.0) | 63.8 ( . ) | 45.8 (26.5, 65.1) | 64.3 (50.4, 78.2) |
| 80+ | 10.7 (5.7, 15.8) | 24.9 (14.7, 35.2) | 20.5 (2.9, 38.0) | 46.7 (34.3, 59.2) | 26.6 (13.9, 39.4) | 42.5 (30.8, 54.2) |
| MEN | ||||||
| 65-69 | 15.2 (6.7, 23.6) | 27.3 (14.7, 39.9) | 16.4 (0.0, 34.7) | 93.5 (79.6, 100) | 59.6 (43.5, 75.6) | 79.5 (68.3, 90.8) |
| 70-74 | 17.4 (8.6, 26.3) | 37.4 (20.5, 54.2) | 39.4 (4.0, 74.7) | 37.5 (1.9, 73.1) | 63.0 (47.8, 78.1) | 80.2 (67.8, 92.6) |
| 75-79 | 12.7 (1.7, 23.7) | 29.9 (19.5, 40.3) | 27.8 (0.0, 84.9) | 40.3 (0.0, 92.7) | 33.4 (22.1, 44.6) | 55.4 (39.8, 71.0) |
| 80+ | 14.0 (8.5, 19.5) | 21.9 (16.4, 27.3) | 21.9 (0.0, 45.5) | 32.9 (0.0, 100) | 32.3 (20.3, 44.2) | 55.3 (44.3, 66.3) |
CI = Confidence interval
CVD = Cardiovascular disease
The following results are from models adjusted for age, gender, race/ethnicity, and CVD and diabetes status using data from the combined 2001-2006 surveys. Compared to those without CVD or diabetes, statin use was more likely in those with diabetes [odds ratio (OR) 2.1, 95% CI 1.8-2.6], CVD but no diabetes (OR 3.0, 95% CI 2.5-3.6), and CVD and diabetes (OR 5.2, 95% CI 3.9-7.1); p=<0.001. There was a trend for women to be somewhat less likely than men to report using a statin, although this did not achieve statistical significance (OR 0.7, 95% CI 0.5-1.1; p=0.09). There was evidence of a trend for those 65-69 to be more likely than those ≥70 years to report taking a statin (OR 0.57, 95% CI 0.39-1.08, p=0.08). This was largely due to non-white persons aged ≥70 reporting less statin use than whites aged 65-69 (OR=0.17, 95% CI 0.10-0.30). A significant interaction between age and gender was found, where 75-79 year old women were more likely to report statin use than men aged 65-69 (OR = 2.07, 95% CI = 1.29, 3.35). Mexican Americans were less likely to report statin use than whites; blacks, other Hispanics, and others reported similar rates as whites. The interaction term for gender and race was not significant (p=0.104).
No CVD or diabetes
Overall 63% of women and 54% of men ≥65 years reported no clinical CVD or diabetes. In women without CVD or diabetes, use of statins alone or in combination increased from 20% of those aged 65-69 to 31% of those aged 75-79, with a drop-off to 16% in those aged 80 and older (Table 2). Men had more consistent use across the age groups, 24-27% in those age 65-74, then about 20% after age 75.
Table 2.
NHANES 2001-2006 Statin use alone or in combination by age group and gender
| No CVD and No Diabetes | No CVD and Diabetes | CVD and No diabetes | CVD and Diabetes | |||||
|---|---|---|---|---|---|---|---|---|
| Age group (years) | Population N (Weighted % of age/race group) | Statin use, % (95% CI) | Population N (Weighted % of age/race group) | Statin use, % | Population N (Weighted % of age/race group) | Statin use, % | Population N (Weighted % of age/race group) | Statin use, % |
| WOMEN | ||||||||
| 65-69-all | 3,998,061 (69.6) | 20.2 (16.3, 24.2) | 810,882 (14.1) | 42.1 (33.7, 50.6) | 528,704 (9.2) | 40.4 (26.1, 54.6) | 408,188 (7.1) | 63.9 (32.7, 95.0) |
| White | 3,279,028 (71.4) | 21.0 (17.8, 24.1) | 574,420 (12.5) | 41.2 (36.1, 46.2) | 405,653 (8.8) | 40.8 (36.3, 45.3) | 332,316 (7.2) | 71.8 (49.9, 93.7) |
| Black | 349,805 (67.5) | 16.0 (10.4, 21.6) | 72,250 (13.9) | 50.8 (0.0, 100) | 68,508 (13.2) | 33.4 ( . ) | 27,518 (4.3) | 58.8 ( . ) |
| Mexican/American | 99,191 (53.1) | 9.0 (5.0, 13.0) | 58,740 (31.4) | 37.1 (17.6, 56.5) | 18,977 (10.1) | 55.0 (0.0, 100) | 9,983 (5.3) | 13.1 ( . ) |
| Other Hispanic | 91,045 (41.0) | 37.7 | 105,472 (47.5) | 44.4 | 20,977 (9.4) | 0 | 4,465 (2.0) | 100 |
| Other | 178,992 (78.7) | 12.6 | - | - | 14,590 (6.4) | - | 33,906 (14.9) | - |
| 70-74-all | 3,346,779 (65.9) | 24.3 (18.2, 30.3) | 756,561 (14.9) | 42.6 (33.2, 52.0) | 644,874 (12.7) | 51.5 (42.0, 61.1) | 327,188 (6.4) | 62.3 (43.0, 81.6) |
| White | 2,789,103 (67.7) | 26.5 (19.8, 33.1) | 615,274 (14.9) | 45.7 (37.6, 53.7) | 526,295 (12.8) | 57.1 (43.1, 71.1) | 186,679 (4.5) | 72.6 (0.0, 100) |
| Black | 271,279 (61.6) | 14.9 (4.1. 25.7) | 53,381 (12.1) | 12.8 ( . ) | 46,419 (10.5) | 13.8 (0.0, 28.6) | 69,275 (15.7) | 40.6 ( . ) |
| Mexican/American | 90,693 (49.3) | 14.7 (10.8, 18.6) | 56,886 (30.9) | 35.9 (30.3, 41.5) | 18,236 (9.9) | 21.2 (13.5, 28.9) | 17,981 (9.8) | 62.6 (0.0, 100) |
| Other Hispanic | 79,573 (71.1) | - | - | - | 32,321 (28.9) | - | - | - |
| Other | 116,131 (52.3) | 18.1 | 31,021 (14.0) | 45.8 | 21,602 (9.7) | - | 53,252 (24.0) | 54.4 ( . ) |
| 75-79-all | 2,422,678 (58.4) | 30.8 (25.9, 35.7) | 505,169 (12.2) | 39.5 (26.4, 52.7) | 878,717 (21.2) | 40.1 (32.2, 47.9) | 341,457 (8.2) | 67.9 (16.3, 100) |
| White | 2,074,465 (59.6) | 32.7 (27.5, 38.0) | 347,448 (10.0) | 34.3 (7.4, 61.2) | 761,281 (21.9) | 42.3 (33.2, 51.4) | 294,324 (8.5) | 72.3 (21.3, 100) |
| Black | 133,968 (37.3) | 17.0 (0.0, 41.6) | 106,770 (29.7) | 40.9 (0.0, 100) | 72,475 (20.2) | 23.8 ( . ) | 45,812 (12.7) | 41.4 ( . ) |
| Mexican/American | 55,984 (59.8) | 14.0 (4.0, 24.1) | 26,700 (28.5) | 47.3 (0.0, 100) | 9,526 (10.2) | 56.6 ( . ) | 1,321 (1.4) | - |
| Other Hispanic | 61,394 (68.5) | - | - | - | 28,227 (31.5) | - | - | - |
| Other | 96,867 (75.5) | 38.0 | 24,250 (18.9) | - | 7,208 (5.6) | - | - | - |
| 80+ - all | 3,805,491 (58.8) | 16.4 (12.3, 20.5) | 673,176 (10.4) | 31.6 (23.7, 39.5) | 1,506,713 (23.3) | 29.0 (21.9, 36.0) | 483,358 (7.5) | 48.1 (32.7, 63.6) |
| White | 3,263,485 (58.3) | 16.8 (12.5, 21.1) | 552,607 (9.9) | 35.4 (25.0, 45.8) | 1,363,584 (24.4) | 31.2 (24.1, 38.4) | 412,847 (7.4) | 49.6 (32.7, 66.4) |
| Black | 271,260 (59.2) | 12.2 (4.1, 20.3) | 44,080 (9.6) | 34.6 ( . ) | 88,865 (19.4) | 9.8 ( . ) | 53,488 (11.7) | 52.2 ( . ) |
| Mexican/American | 70,187 (54.7) | 11.8 (6.4, 17.1) | 26,274 (20.5) | 7.3 ( . ) | 22,332 (17.4) | 7.8 ( . ) | 9,405 7.3) | - |
| Other Hispanic | 117,168 (81.1) | 5.7 | 19,641 (12.6) | - | - | - | 7,618 (5.3) | - |
| Other | 83,391 (57.4) | 32.9 | 30,574 (21.0) | - | 31,392 (21.6) | - | - | - |
| MEN | ||||||||
| 65-69-all | 2,666,981 (55.1) | 23.6 (16.7, 30.4) | 736,235 (15.2) | 44.7 (30.3, 59.1) | 873,082 (18.0) | 63.0 (50.2, 75.8) | 566,962 (11.7) | 64.2 (51.1, 77.3) |
| White | 2,131,629 (54.7) | 23.6 (16.7, 30.6) | 565,437 (14.5) | 45.1 (26.0, 64.1) | 752,722 (19.3) | 65.2 (50.4, 79.9) | 442,836 (11.4) | 64.8 (46.7, 82.9) |
| Black | 277,194 (57.1) | 23.7 (12.5, 34.9) | 96,432 (19.9) | 26.1 (0.0, 84.0) | 44,971 (9.3) | 32.9 (0.0, 100) | 67,149 (13.8) | 44.4 (15.9, 72.9) |
| Mexican/American | 96,559 (51.3) | 14.7 (9.3, 20.1) | 42,902 (22.8) | 41.5 (24.1, 58.9) | 26,396 (14.0) | 42.4 (0.0, 100) | 22,272 (11.8) | 56.1 ( . ) |
| Other Hispanic | 91,470 (83.7) | 37.3 | 17,777 (16.3) | - | - | - | - | - |
| Other | 70,129 (41.9) | 14.6 | 13,688 (8.2) | - | 48,994 (29.2) | 68.4 | 34,704 (20.7) | - |
| 70-74-all | 2,346,546 (58.3) | 27.3 (19.7, 35.0) | 582,976 (14.5) | 30.6 (17.6, 43.7) | 760,187 (18.9) | 60.9 (52.4, 69.4) | 332,492 (8.3) | 71.2 (59.8, 82.6) |
| White | 1,980,087 (58.7) | 31.2 (22.7, 39.7) | 465,000 (13.8) | 34.7 (19.4, 49.9) | 652,046 (19.3) | 60.8 (51.4, 70.3) | 274,456 (8.1) | 74.2 (54.4, 94.0) |
| Black | 141,141 (52.1) | 8.0 (7.6, 8.5) | 60,701 (22.4) | 16.7 (0.0, 36.6) | 34,059 (12.6) | 55.1 ( . ) | 34,748 (12.8) | 34.8 (0.0, 100) |
| Mexican/American | 94,798 (64.4) | 5.4 (0.0, 12.6) | 29,361 (20.0) | 25.1 (11.2, 39.1) | 14,473 (9.8) | 17.2 ( . ) | 8,388 (5.7) | 72.6 ( . ) |
| Other Hispanic | 112,814 (67.0) | 2.7 | 27,915 (16.6) | 0 | 27,687 (16.4) | 87.0 | 0 (0) | 0 |
| Other | 17,706 (27.4) | 21.2 | 0 (0) | 0 | 31,921 (49.5) | 66.4 | 14,901 (23.1) | 100 |
| 75-79-all | 1,689,186 (54.1) | 19.8 (14.5, 25.2) | 358,268 (11.5) | 37.6 (16.5, 58.7) | 789,726 (25.3) | 44.0 (34.5, 53.4) | 284,249 (9.1) | 41.1 (21.4, 60.9) |
| White | 1,429,912 (53.3) | 21.5 (15.8, 27.3) | 294,044 (10.9) | 42.2 (15.2, 69.1) | 726,239 (27.1) | 44.1 (38.2, 50.1) | 232,145 (8.7) | 41.2 (18.7, 63.8) |
| Black | 153,006 (61.5) | 15.9 (11.7, 20.0) | 24,739 (9.9) | 43.0 ( . ) | 43,487 (17.5) | 50.6 (17.0, 84.3) | 27,461 (11.0) | 69.8 ( . ) |
| Mexican/American | 38,620 (55.1) | 6.9 (0.0, 14.8) | 13,395 (19.1) | 0 ( . ) | 14,669 (20.9) | 33.0 (0.0, 100) | 3,410 (4.9) | 58.7( . ) |
| Other Hispanic | 42,443 (88.9) | 0.0 | 5,307 (11.1) | 0 | 0 (0) | 0 | 0 (0) | 0 |
| Other | 25,206 (34.7) | 0.0 | 20,783 (28.6) | 0 | 5,331 (7.3) | 0 | 21,233 (29.3) | 0 |
| 80+ - all | 1,656,199 (48.1) | 18.5 (15.0, 22.1) | 279,603 (8.1) | 23.3 (15.4, 31.3) | 1,261,380 (36.6) | 43.5 (37.3, 49.8) | 245,161 (7.1) | 48.7 (39.6, 57.8) |
| White | 1,449,076 (47.2) | 19.3 (15.3, 23.4) | 231,716 (7.5) | 26.6 (16.6, 36.6) | 1,171,803 (38.2) | 45.2 (38.8, 51.7) | 216,474 (7.1) | 50.9 (40.1, 61.6) |
| Black | 88,715 (56.9) | 17.2 (7.7, 26.7) | 15,182 (9.7) | 17.8 ( . ) | 31,996 (20.5) | 19.6 (14.0, 25.2) | 20,097 (12.9) | 19.2 ( . ) |
| Mexican/American | 51,117 (58.9) | 5.2 (0.0, 40.4) | 16,190 (18.6) | 5.6 (0.0, 14.1) | 13,228 (15.2) | 7.2 ( . ) | 6,280 (7.2) | 86.5 ( . ) |
| Other Hispanic | 41,155 (52.7) | - | 13,830 (17.7) | - | 20,732 (26.6) | 15.0 | 2,310 (3.0) | - |
| Other | 26,136 (49.8) | 33.8 | 2,685 (5.1) | - | 23,621 (45.0) | 36.7 | - | - |
CI = Confidence interval
CVD = Cardiovascular disease
Among those without CVD or diabetes not reporting the use of cholesterol-lowering drugs (Table 3), half of women aged 65-69 had an LDL-C ≥139 mg/dL and a non-HDL-C ≥156 mg/dL. Median LDL-C and non-HDL levels declined with advancing age, such that by age ≥80, half of women had an LDL-C ≥124 mg/dL and non-HDL-C ≥151 mg/dL. For most age-sex groups, median LDL-C and non-HDL-C levels similarly declined with age, although medians were slightly lower for men.
Table 3.
NHANES 2001-2006 Median LDL-C (fasting) and non-HDL-C (fasting and non-fasting) in those reporting no use of statins or other cholesterol-lowering drugs
| No CVD and No Diabetes | No CVD and Diabetes | CVD and No diabetes | CVD and Diabetes | |||||
|---|---|---|---|---|---|---|---|---|
| Age (years) Race/ethnicity | LDL-C (IQR) | Non-HDL-C (IQR) | LDL-C (IQR) | Non-HDL-C (IQR) | LDL-C (IQR) | Non-HDL-C (IQR) | LDL-C (IQR) | Non-HDL-C (IQR) |
| WOMEN | ||||||||
| 65-69-all | 139 (112-157) | 156 (137-189) | 113 (104-133) | 164 (135-210) | 137 (136-150) | 156 (149-178) | 113 (113-113) | 139 (134-196) |
| White | 139 (112-156) | 154 (134-189) | 106 (100-113) | 172 (138-211) | 143 (137-234) | 156 (149-186) | . | 139 (135-208) |
| Black | 153 (119-168) | 169 (143-197) | 109 (104-127) | 145 (140-152) | 133 (117-142) | 155 (155-184) | . | 174 (174-174) |
| Mexican/American | 119 (109-141) | 161 (143-175) | 129 (92-139) | 173 (135-186) | 164 (129-171) | 148 (145-203) | 121 (121-145) | 151 (132-220) |
| 70-74-all | 136 (113-159) | 165 (139-190) | 115 (91-142) | 158 (112-175) | 126 (114-136) | 152 (135-182) | 72 (72-125) | 188 (137-196) |
| White | 142 (115-162) | 166 (139-191) | 115 (95-142) | 159 (132-177) | 126 (117-137) | 152 (135-182) | . | 196 (1188-206) |
| Black | 122 (88-156) | 152 (123-180) | 121 (63-121) | 154 (111-158) | 114 (114-114) | 140 (140-144) | 72 (72-72) | 131 (97-156) |
| Mexican/American | 136 (112-136) | 159 (137-168) | 115 (83-139) | 165 (129-174) | 40 (40-136) | 167 (54-175) | 125 (104-125) | 159 (104-159) |
| 75-79-all | 126 (91-148) | 151 (126-175) | 130 (91-190) | 172 (134-196) | 131 (125-146) | 160 (138-180) | . | 143 (128-177) |
| White | 126 (98-148) | 147 (126-175) | 130 (126-190) | 172 (153-202) | 127 (125-157) | 159 (138-184) | . | 143 (128-189) |
| Black | 142 (71-160) | 140 (92-185) | 72 (58-103) | 131 (92-173) | 131 (131-146) | 161 (110-163) | . | 123 (103-123) |
| Mexican/American | 140 (113-151) | 164 (143-194) | 114 (114-114) | 163 (163-168) | . | 135 (126-135) | . | . |
| 80+ - all | 124 (95-143) | 151 (125-176) | 143 (115-145) | 162 (127-185) | 119 (94-144) | 156 (133-175) | 99 (86-143) | 144 (130-196) |
| White | 128 (104-144) | 153 (127-178) | 140 (115-144) | 163 (127-183) | 119 (94-144) | 153 (131-175) | 124 (86-143) | 148 (132-196) |
| Black | 95 (85-129) | 135 (104-159) | . | 130 (113-130) | 109 (59-182) | 150 (141-188) | 82 (82-82) | 98 (98-136) |
| Mexican/American | 146 (102-148) | 149 (112-174) | 92 (92-136) | 168 (110-270) | 128 (124-142) | 168 (152-193) | . | . |
| MEN | ||||||||
| 65-69-all | 136 (106-153) | 162 (137-178) | 132 (98-142) | 154 (118-169) | 111 (87-126) | 150 (124-162) | 124 (107-134) | 148 (129-175) |
| White | 133 (104-152) | 163 (138-181) | 134 (98-152) | 154 (118-164) | 87 (84-127) | 153 (133-188) | 124 (70-134) | 147 (129-174) |
| Black | 139 (76-173) | 152 (119-168) | 98 (63-159) | 142 (124-187) | 111 (94-115) | 124 (112-141) | 139 (139-155) | 175 (162-216) |
| Mexican/American | 144 (107-158) | 172 (145-183) | 118 (103-134) | 157 (136-183) | 169 (104-173) | 147 (135-154) | 177 (177-177) | 146 (146-227) |
| 70-74-all | 122 (105-144) | 150 (132-176) | 117 (99-127) | 141 (120-166) | 121 (100-148) | 149 (140-175) | 90 (80-90) | 125 (114-140) |
| White | 121 (110-142) | 150 (132-175) | 117 (80-130) | 144 (119-174) | 121 (116-148) | 149 (140-175) | 90 (90-90) | 123 (114-140) |
| Black | 97 (79-118) | 128 (115-154) | 99 (99-139) | 145 (112-164) | 100 (100-132) | 110 (110-158) | 80 (78-80) | 134 (98-134) |
| Mexican/American | 143 (131-160) | 167 (141-188) | 125 (87-137) | 156 (139-170) | 133 (133-147) | 127 (116-163) | 66 (66-66) | 109 (109-236) |
| 75-79-all | 126 (98-145) | 151 (123-174) | 119 (97-166) | 144 (117-191) | 115 (95-134) | 138 (114-178) | 148 (119-148) | 143 (128-177) |
| White | 125 (103-154) | 151 (125-174) | 119 (97-166) | 157 (117-191) | 115 (95-134) | 138 (117-178) | 148 (148-148) | 191 (134-224) |
| Black | 128 (89-145) | 151 (110-183) | . | 134 (107-134) | 96 (76-160) | 155 (112-183) | . | 102 (102-102) |
| Mexican/American | 122 (97-126) | 156 (122-192) | 108 (104-148) | 132 (111-140) | . | 157 (136-179) | 119 (119-119) | 138 (138-138) |
| 80+ - all | 121 (100-138) | 145 (120-168) | 119 (95-121) | 148 (127-166) | 117 (98-143) | 145 (113-170) | 107 (81-117) | 144 (130-196) |
| White | 121 (100-138) | 142 (120-166) | 119 (106-121) | 148 (138-165) | 120 (99-143) | 146 (113-172) | 117 (117-145) | 137 (135-186) |
| Black | 122 (90-135) | 136 (115-155) | 95 (95-95) | 166 (113-223) | 55 (55-124) | 103 (100-139) | 85 (75-96) | 123 (112-127) |
| Mexican/American | 109 (84-116) | 132 (106-161) | 134 (134-154) | 194 (167-196) | 97 (97-151) | 154 (143-163) | . | . |
CI = Confidence interval
CVD = Cardiovascular disease
HDL-C = High density lipoprotein cholesterol
IQR = Interquartile range
LDL-C = Low density lipoprotein cholesterol
Among those without CVD or diabetes reporting cholesterol-lowering drug use (Table 4), women aged 65-69 had the lowest median LDL-C (89 mg/dL). Men aged 65-69 had a slightly higher median LDL-C of 105 mg/dL. Median LDL-C was 94-103 mg/dL and median non-HDL-C was 116-143 mg/dL in the other age-sex groups
Table 4.
NHANES 2001-2006 Median LDL-C (fasting) and non-HDL-C (fasting and non-fasting) in those reporting use of a statin as monotherapy
| No CVD and No Diabetes | No CVD and Diabetes | CVD and No diabetes | CVD and Diabetes | |||||
|---|---|---|---|---|---|---|---|---|
| Age/race/ethnicity | LDL-C (IQR) | Non-HDL-C (IQR) | LDL-C (IQR) | Non-HDL-C (IQR) | LDL-C (IQR) | Non-HDL-C (IQR) | LDL-C (IQR) | Non-HDL-C (IQR) |
| WOMEN | ||||||||
| 65-69-all | 89 (83-107) | 132 (117-148) | 88 (77-95) | 111 (104-128) | 96 (84-96) | 114 (108-149) | 121 (85-168) | 118 (107-173) |
| White | 89 (83-107) | 132 (115-148) | 84 (77-88) | 111 (104-128) | 96 (96-96) | 119 (108-162) | 121 (85-168) | 118 (107-173) |
| Black | 111 (74-142) | 120 (110-132) | 89 (34-112) | 111 (90-138) | 116 (85-116) | 122 (110-140) | 114 (114-114) | 106 (54-125) |
| Mexican/American | 58 (58-65) | 127 (87-161.5) | 84 (56-127) | 106 (100-115) | 89 (63-89) | 117 (102-149) | . | . |
| 70-74-all | 100 (97-121) | 137 (121-155) | 79 (67-100) | 123 (107-142) | 103 (89-144) | 147 (116-173) | 136 (91-136) | 153 (118-158) |
| White | 100 (97-123) | 137 (121-157) | 97 (67-100) | 135 (107-142) | 134 (89-144) | 147 (116-173) | . | 153 (84-158) |
| Black | 94 (87-94) | 109 (109-140) | . | 133 (133-133) | . | 106 (106-106) | 136 (91-136) | 169 (153-169) |
| Mexican/American | 107 (101-153) | 145 (129-178) | 119 (108-127) | 130 (113-152) | . | 137 (137-164) | 76 (76-76) | 109 (107-125) |
| 75-79-all | 103 (90-120) | 143 (117-153) | 90 (57-113) | 106 (94-145) | 95 (90-102) | 127 (111-162) | 90 (82-99) | 122 (116-139) |
| White | 103 (90-120) | 143 (115-151) | 103 (59-113) | 125 (83-160) | 95 (90-102) | 127 (111-153) | 90 (82-99) | 122 (116-139) |
| Black | 114 (108-114) | 133 (132-140) | 90 (55-101) | 106 (88-145) | 60 (60-60) | 107 (85-107) | . | 127 (127-127) |
| Mexican/American | 54 (54-124) | 172 (166-175) | 92 (44-107) | 126 (107-177) | 147 (147-147) | 167 (167-196) | . | . |
| 80+ - all | 99 (79-120) | 127 (106-148) | 72 (62-115) | 121 (102-152) | 88 (50-114) | 128 (98-148) | 81 (80-104) | 106 (101-144) |
| White | 99 (79-121) | 129 (109-148) | 72 (62-98) | 121 (102-149) | 88 (50-114) | 128 (98-148) | 81 (81-104) | 102 (101-121) |
| Black | 120 (120-120) | 136 (102-212) | 118 (118-118) | 152 (90-152) | . | . | 77 (77-77) | 144 (107-155) |
| Mexican/American | 113 (65-113) | 150 (145-150) | . | . | . | 166 (166-166) | . | . |
| MEN | ||||||||
| 65-69-all | 105 (86-124) | 137 (115-151) | 99 (91-118) | 143 (112-158) | 107 (73-120) | 117 (108-140) | 72 (47-110) | 129 (100-149) |
| White | 98 (64-109) | 130 (115-154) | 93 (91-118) | 143 (112-158) | 102 (73-120) | 115 (108-140) | 99 (72-110) | 145 (122-159) |
| Black | 91 (78-108) | 128 (111-146) | 99 (99-150) | 146 (129-150) | 70 (70-70) | 102 (102-158) | 76 (57-78) | 93 (92-137) |
| Mexican/American | 83 (83-114) | 179 (139-192) | 92 (92-122) | 133 (130-143) | 69 (69-69) | 126 (91-126) | 33 (33-33) | 125 (68-132) |
| 70-74-all | 98 (87-109) | 126 (110-138) | 85 (62-92) | 112 (90-123) | 71 (67-98) | 125 (106-144) | 64 (55-118) | 109 (88-140) |
| White | 98 (87-109) | 125 (110-137) | 85 (75-92) | 112 (90-149) | 71 (67-104) | 125 (107-144) | 64 (55-118) | 109 (90-140) |
| Black | 139 (139-139) | 128 (102-128) | 56 (56-56) | 101 (66-123) | 80 (80-127) | 99 (90-120) | 52 (52-108) | 129 (80-148) |
| Mexican/American | 119 (83-119) | 138 (104-138) | 62 (62-78) | 106 (91-111) | 81 (81-81) | 122 (122-122) | . | 172 (67-172) |
| 75-79-all | 102 (88-111) | 130 (119-151) | 82 (82-104) | 124 (90-154) | 79 (77-84) | 115 (101-127) | 68 (61-103) | 94 (72-99) |
| White | 102 (95-111) | 130 (110-151) | 82 (82-104) | 124 (90-129) | 79 (77-84) | 115 (101-127) | 61 (61-103) | 94 (72-99) |
| Black | 112 (112-112) | 134 (122-159) | 83 (83-83) | 126 (111-154) | 79 (79-79) | 110 (97-115) | 68 (68-96) | 101 (87-117) |
| Mexican/American | 83 (46-83) | 129 (66-129) | . | . | 67 (67-67) | 129 (109-194) | 68 (68-68) | 106 (106-106) |
| 80+ - all | 94 (77-118) | 116 (100-141) | 104 (50-112) | 110 (98-130) | 88 (72-96) | 112 (95-130) | 78 (51-81) | 111 (83-122) |
| White | 94 (77-111) | 116 (100-141) | 104 (50-112) | 110 (98-130) | 88 (72-96) | 112 (94-130) | 78 (51-81) | 111 (83-122) |
| Black | 146 (55-146) | 169 (66-169) | . | 146 (146-146) | . | . | . | . |
| Mexican/American | . | 109 (109-122) | . | 105 (105-105) | 99 (99-99) | 128 (128-128) | 75 (62-103) | 118 (83-157) |
CI = Confidence interval
CVD = Cardiovascular disease
HDL-C = High density lipoprotein cholesterol
IQR = Interquartile range
LDL-C = Low density lipoprotein cholesterol
Diabetes but no CVD
Overall 13% of women and men ≥65 years reported diabetes but no CVD, with prevalence falling to about 10% in the ≥80 age group. In women, 40-43% of those aged 65-79 reported statin use, with somewhat lower use in those ≥80 years (32%) [Table 2]. Statin use was reported by 45% of men aged 64-69, with lower use in those in their 70’s (31-38%), declining to 23% by men ≥80 years. More specimens were available for non-HDL-C since fasting was not required.
Among those with diabetes but no CVD not reporting cholesterol-lowering drug use (Table 3), median LDL-C levels were 113-130 mg/dL in women age 65-79, with a median of 143 in women ≥80 years. In men, median LDL-C levels were 132 mg/dL in men aged 65-69 years, but lower in those ≥70 years (117-119 mg/dL).
Among those with diabetes but no CVD who did report cholesterol-lowering drug use (Table 4), median LDL-C levels were 72-90 mg/dL in women. In men, median LDL-c was fell from 99 mg/dL in men 65-79 to 82 mg/dL in men aged 75-79 In women, median non-HDL-C levels were 111-123 mg/dL, and in men 110-124 mg/dL in those ≥70 years, and 143 mg/dL in those aged 65-69.
CVD no diabetes
Overall 17% of women and 24% of men ≥65 years had CVD without diabetes. The proportion of women reporting CVD but without diabetes increased with advancing age, from 9% in those aged 65-69 to 23% by age ≥80 (Table 2). In men, 18% reported CVD without diabetes in the 65-69 group, which increased to 37% by age ≥80. Statin use in women peaked in the 70-74 age group at 52%, with a 40% reporting use in younger and older 5-year age groups, and fell to 29% in those ≥80 years. Men with CVD but without diabetes reported higher rates of statin use by every age group, with 61-63% reporting use in the 65-74 age group and 44% in those ≥75 years.
Among those with CVD but no diabetes who did not report statin use (Table 3), median LDL-C was 137 mg/dL in women aged 65-69 and fell to 119 mg/dL in those ≥80 years. In men, the median LDL-C ranged from 111 to 121 mg/dL. Median non-HDL-C was 152-160 mg/dL in women, and 138-150 mg/dL in men.
Among those with CVD but no diabetes who reported statin use (Table 4), median LDL-C was 95-103 mg/dL in women aged 65-79, and 88 mg/dL in those ≥80 years. In men, LDL-C was highest at 107 mg/dL in the 65-69 group, and 71-88 in those ≥70 years. Median non-HDL-C was 114-128 mg/dL in women, with the exception of age 70-74 with median non-HDL-C of 147 mg/dL. Men had median non-HDL-C levels of 112-125 mg/dL.
CVD and diabetes
Overall, 7% of women and 9% of men ≥65 years had both CVD and diabetes (Table 2). In men, 12% reported CVD and diabetes in the 65-69 age group, which fell to 7% by age ≥80. Before age 80, 62-68% of women reported using statin, with a drop-off to 48% in the ≥80 age group. In men, before age 75, 64-71% reported using statins, with a drop-off to 41-49% in those ≥75 years.
In those with CVD and diabetes did not report using a statin, few data were available for LDL-C (Table 3). More data were available for non-HDL-C, which ranged from 139-188 in women and 125-148 in men.
In those with CVD and diabetes who reported using a statin (Table 4), median LDL-C was 121-136 mg/dL in women aged 65-74, and 81-90 in those ≥75 years Table. In men, median LDL-C was 64-78 mg/dL. Median non-HDL-C was highest in women aged 70-74 (153 mg/dL), and ranged from 106-122 mg/dL in women in other age groups. In men, median non-HDL-C ranged from 94-129 mg/dL.
LDL-C <100 mg/dL
In those without CVD or diabetes, age and gender did not influence achieving an LDL-C<100 mg/dL or non-HDL-C<130 mg/dL, while Hispanics were less likely to achieve this goal than other groups (p<0.001). However, in those with CVD or diabetes, attainment of LDL-C <100 mg/dL was more likely in those ≥75 years (p=0.02) and in non-whites (p<0.001), while gender did not influence goal attainment (p=0.18); non-whites had similar rates of non-HDL-C goal attainment as whites.
Discussion
Although statin use increased in persons ≥65 years in the period between 2001 and 2006, treatment rates still remained suboptimal during this time period. Underutilization of statins occurred in every risk category, although rates improved with increasing levels of risk. The greatest improvements in statin use occurred in men with CVD or diabetes, with statin use in women generally lagging behind men before age 75. Although diabetes is considered a CHD risk equivalent in the National Cholesterol Program Adult Treatment Panel (ATP) III guidelines,9 statins were used by fewer individuals ≥70 with diabetes without CVD than in those with CVD (with or without diabetes). In those with CVD, statin use declined after age 75 in men and 80 in women. Non-whites were generally less likely to receive statins than nonwhites.
In primary prevention population of individuals without clinically evident CVD or diabetes, the large majority of men 65-69 and all men aged 70-79 on the basis of age alone, have ≥10% 10-year coronary heart disease (CHD) risk and statin therapy should be considered for LDL-C were ≥130 mg/dl and could be considered for LDL-C ≥100 mg/dL according to the 2004 ATP III update.9, 10 This population-based analysis revealed that ≤27% of men in this age group were receiving statin therapy while about half of still had an LDL-C >100 mg/dL. Among those not receiving a statin, >75% would be eligible for a statin due to LDL-C >100 mg/dL. In the primary prevention population of women, relatively few have a 10-year CHD risk ≥10% before age 75, although most women ≥75 will have ≥10% risk on the basis of age and hypertension.11 Despite the large difference between men and women in the proportion with ≥10-year CHD before age 75, similar proportions reported statin therapy. Statin utilization rates were similar in white and on-white groups before age 70, but disparities in statin use became increasingly evident with advancing age. More data are needed for non-white groups.
Statin use consistently declined after age 80. Although statin therapy is recommended for individuals ≥80 years with CVD or diabetes as a CHD risk equivalent, risk stratification in those ≥80 years these conditions is not recommended according to current guidelines.10 Instead, individualized use of statins is recommended for the oldest patients. Lack of evidence from randomized trials of benefit in the face of competing causes of morbidity and mortality and concerns about safety no doubt contribute to the lower rates of statin utilization after age 80.5
Limitations
Despite merging 3 2-year NHANES surveys, insufficient numbers non-white persons were available for comparisons of various age-sex-disease status subgroups. Since this was a cross-sectional survey, data were not available on long-term adherence patterns.
Conclusion
Increasing rates of statin use by the elderly have no doubt contributed to the encouraging declines in CVD morbidity and mortality over the past decade. It appears that the 2001 and 2004 recommendations by NCEP ATP III for more aggressive for lipid treatment did translate into greater utilization in clinical practice. However, statin use remains suboptimal and efforts to increase statin utilization for both the primary and secondary prevention of CVD in the elderly should continue. Efforts to address disparities in statin use with advancing age, in women, and non-whites are also needed. Since the risks and benefits of statins in individuals ≥80 years are unclear, a randomized trial is needed to guide statin treatment.
Acknowledgments
None
Funding sources: This project was supported in part by an Agency for Healthcare Research and Quality (AHRQ) Centers for Education and Research on Therapeutics cooperative agreement #5 U18 HSO16094.
Footnotes
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