Hyperlipidemia in Older Adults
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Case Vignette
An 87-year-old man with well-controlled hypertension and no known cardiovascular disease had his cholesterol checked at a local health fair. He comes to the physician’s office with the following results: total cholesterol 245 mg/dL, triglycerides 141 mg/dL, high-density lipoprotein cholesterol (HDL-C) 57 mg/dL, and low-density lipoprotein cholesterol (LDL-C) 160 mg/dL. He is very functional and active, with no symptoms of angina or heart failure. How should this patient be managed?
Introduction
The National Cholesterol Education Program (NCEP) guidelines for the Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults recommend management based on the patient’s individual risk of coronary events without providing age-specific treatment guidelines (Table I).1 However, estimating the risk of developing coronary artery disease (CAD) is particularly challenging in older persons, as projections based on population studies such as Framingham have not been validated in patients over 75 years of age. In addition to uncertainty regarding the risk of CAD in this age group, there is also debate as to the degree to which hyperlipidemia contributes to this risk, and whether or not the risk is materially modified by cholesterol-lowering therapy. In this review, we discuss the relationship between age and lipid levels, the role of hyperlipidemia as a risk factor for CAD in older patients, the data supporting lipid-lowering therapy for primary and secondary prevention, and special treatment considerations when treating older patients.
Normal Lipid Levels in Older Adults
Several cross-sectional population studies have demonstrated that total cholesterol and LDL-C levels increase after the onset of puberty until 50 years of age, and then plateau until 70 years of age. After 70 years of age, cholesterol and LDL-C levels decline somewhat, with the effect being stronger in men than in women.2,3 In addition, although women have lower cholesterol levels than men prior to menopause,3 older women have higher total cholesterol, LDL-C, and HDL-C levels than men of similar age.2 Some of the differences observed across age groups in cross-sectional analyses can be explained by the earlier death of people with an atherogenic lipid profile; however, longitudinal analyses indicate that these changes are unlikely to be due to survival bias alone.4 While many factors may contribute to alterations in the lipid profile, the most important appears to be a gradual decrease in weight after the age of 50 years.4 Declines in sex hormones in both women and men, cessation of smoking, and reduction in alcohol intake and exercise contribute to lower HDL-C levels in older adults. Thus, although screening older persons who have never been tested may be appropriate, repeated screening is probably not necessary because lipid levels are unlikely to increase after 60 years of age.
Despite the fact that lipid levels decrease modestly with age, there are still large numbers of older persons with elevated cholesterol. In the Cardiovascular Health Study,5 among 4810 men and women age 65 years and older not taking lipid-lowering therapy, 24% had total cholesterol levels higher than 240 mg/dL and 46% had LDL-C levels higher than 160 mg/dL. However, as a result of improved nutritional habits and other health behaviors, in addition to increased pharmaceutical treatment of hyperlipidemia, population-based studies have encouragingly shown that lipid levels have been decreasing over time.3,6
Role of Cholesterol in Coronary Artery Disease in the Elderly
While high total cholesterol and LDL-C levels are well-established risk factors for cardiovascular events and mortality in middle-aged patients,7,8 the relationship between lipid levels and mortality among older individuals is less certain.
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