Prevalence and Correlates of Statin Underuse for Secondary Prevention of Cardiovascular Disease in Older Adults 65–79 Years of Age: The Italian Health Examination Survey 2008

Abstract

Limited data are available on the prevalence and correlates of statin use for secondary cardiovascular (CV) prevention in the older adult population. We used data of older adults (65–79 years) with established atherosclerotic CV disease from the cross-sectional Italian Health Examination Survey 2008–2012 to address this issue. Lifestyles, CV risk factors, chronic diseases, and therapies were assessed using standardized procedures. A comprehensive geriatric assessment was performed to evaluate cognitive function, disability in basic activities of daily living/instrumental activities of daily living, mobility, and polypharmacy. Multiple regression analyses were performed to identify independent correlates of statin use. A total of 392 participants (mean age 72.1 ± 4.4 years, 61.5% men) were considered for this analysis. Coronary heart disease was identified in 67.1% of participants, cerebrovascular disease in 23.5%, and peripheral artery disease (PAD) in 18.1%. One hundred ninety (48.5%) were statin users. By multiple regression analysis, functional disability (odds ratio [OR] = 0.81; 95% confidence interval [CI] = 0.71–0.92; p = 0.002), cognitive impairment (OR = 0.87; 95% CI = 0.78–0.98; p = 0.018), and polypharmacy (OR = 0.86; 95% CI = 0.75–0.98; p = 0.035) predicted statin nonuse, whereas having hypertension (OR = 1.19; 95% CI = 1.05–1.34; p = 0.005), diabetes mellitus (OR = 1.14; 95% CI = 1.03–1.27; p = 0.013), or a previous myocardial revascularization (OR = 1.31; 95% CI = 1.16–1.48; p < 0.001) predicted statin use. Significant interaction terms were observed between cerebrovascular disease, PAD, cognitive impairment, and disability in predicting statin nonuse. Statin underuse in older adults aged 65–79 years with CV disease, and thus suboptimal secondary CV prevention, is highly prevalent despite current guidelines and recommendations. Common geriatric conditions are associated with statin nonuse. Such results support the need for improving the awareness of statin treatment for secondary CV prevention.

Introduction

Evidence consistently indicates the benefit of statin treatment in patients with established cardiovascular (CV) diseases to prevent recurrence of CV events.^1,2 Current guidelines recommend statin treatment for secondary CV prevention in patients with ischemic CV disease of atherosclerotic origin, that is, coronary heart disease (CHD), ischemic stroke or transient ischemic attack (TIA), and peripheral artery disease (PAD).² However, there might be a substantial gap between current guidelines and recommendations and clinical practice.^3

–6 In fact, real-world patients are usually older and have greater comorbidity burden when compared with those enrolled in trials.³ Although there is an overall insufficient level of evidence to make firm recommendations for older patients, there is general agreement that they should receive at least a moderate-intensity treatment for secondary prevention.¹ Underprescription of statins in older people might have several explanations, for example, uncertainty about benefit,³ perceived increased risk of adverse interactions with other drugs, and concerns about tolerability.^8,9,10 Furthermore, it has been shown that among patients with overt CV disease, those with ischemic stroke,^10,11,12 or PAD,^13,14 might be less likely to receive statin treatment when compared with those with CHD. Given the high prevalence of CV disease in older adults and their associated burden of disability,¹⁵ updated population-based data assessing the dimension and correlates of statin underuse are of eminent importance for public health. We hypothesize that statin underuse in secondary prevention is highly prevalent among older adults and that common geriatric conditions, for example, functional disability, cognitive impairment, and polypharmacy, predict statin underuse at the population level. We addressed this issue using data from the Italian Health Examination Survey (HES) 2008–2012.

Methods

Study population

The Italian HES 2008–2012 is a cross-sectional epidemiological survey conducted between April 2008 and July 2012 on representative samples of the general Italian adult population. The samples were extracted from the residence lists of 23 municipalities from all the 20 Italian regions, with planned inclusion of 220 individuals for every 1.5 million inhabitants. The survey was launched by the Italian Ministry of Health and realized by joint action of the Italian National Institute of Health (ISS) and the National Association of Hospital Cardiologists/Heart Care Foundation, with the aim to provide a comprehensive picture of the population's health by evaluation of lifestyles, dietary patterns, and risk factors for chronic degenerative diseases.^16,17 Methods used for sample recruitment and variable collection are better described elsewhere.^16,17 Clinical interviews and examinations were performed by trained staff. All procedures were standardized and kept under quality control by ISS staff throughout the survey. Overall, the participation rate of older adults was 48.4%. Rates were higher in men than in women (51.7% vs. 45.2%, p = 0.001) and lower in southern when compared with northern and central regions (43.6% vs. 51.1%, p < 0.001). The study was approved by the local ethics committee of the ISS. Written informed consent to the study was obtained from all participants. For this analysis, we included all subjects ≥65 years of age with established atherosclerotic CV disease. We excluded those with a history of stroke or TIA associated with atrial fibrillation, due to probable embolic etiology, and those not assessed for cognitive impairment and functional disability. Of note, all the included subjects were eligible for statin treatment according to current guidelines.

Clinical evaluation and medications

Trained staff administered a questionnaire assessing personal and medical history, measured anthropometric features, and collected biological samples.¹⁶ CV comorbidity was also assessed by measured CV risk factors, that is, blood pressure (BP), body–mass index, lipids, and glycemia. Hypertension was defined by BP levels ≥140/90 mmHg or use of antihypertensive medications and diabetes mellitus was defined by fasting glycemia ≥126 mg/dL or diabetes diagnosis or treatment. Fasting lipids and glucose were measured in serum samples using commercially available enzyme colorimetric kits (Instrumentation Laboratory, Milan, Italy) and an automatic analyzer (IL 350). Low-density lipoprotein (LDL) cholesterol was calculated using the Friedewald formula. Chronic diseases were identified by information from clinical interview and medical records and by objective evidence. Chronic kidney disease (CKD) was defined by the creatinine-based, estimated glomerular filtration rate (CKD-EPI equation) and 24-hour urinary albumin-to-creatinine ratio, according to the KDIGO 2012 guidelines.^18,19 The definition of CHD included the following items: the prevalence of a previous myocardial infarction evaluated using the London School of Hygiene and Tropical Medicine (LSHTM) questionnaire,²⁰ which included symptoms, hospital records, and electrocardiogram findings according to the Minnesota Code; the presence of angina pectoris evaluated using the LSHTM questionnaire; and history of myocardial revascularization procedures (percutaneous transluminal coronary angioplasty [PTCA] and coronary aortic bypass grafting [CABG]) by self-report or review of medical records. Cerebrovascular events, that is, ischemic stroke and TIA, were defined by self-reported diagnoses and review of medical records. PAD was defined by self-reported diagnoses, review of medical records, or by symptoms of claudication associated with clinical evidence of lower limb artery disease. Current medications were ascertained by study staff at the in-person visit and confirmed by review of any available medical record. Medications were assigned an anatomic therapeutic chemical (ATC) code. In particular, hydroxy-methyl-glutaryl-coenzyme-A reductase inhibitors, that is, statins, were assigned the ATC code C10AA. Polypharmacy was defined as the subject using five or more daily medications, regardless of the class of medication, based upon widely used definitions in literature.²¹

Geriatric assessment

Cognitive function was evaluated using Folstein's Mini-Mental State Examination (MMSE).²² MMSE scores were adjusted for age and education according to standard procedures. Comprehensive scores range from 0 to 30; the higher the score, the better the cognitive function. By convention, cognitive impairment was defined by an MMSE score <24/30.²² Functional disability in basic activities of daily living (ADL), instrumental activities of daily living (IADL), and mobility was assessed using a standardized questionnaire.²³ Disability in ADL/IADL was defined as the subject being unable or requiring help or supervision to perform one or more of the following tasks: (1) dress and undress; (2) take a bath or shower; (3) go to the toilet; (4) use the telephone; and (5) light housework. Mobility disability was defined as the subject being unable or requiring help or supervision to perform one or both of the following tasks: (1) walk 500 m and (2) climb a flight of stairs.

Statistical analyses

All analyses were done using the Statistical Package for Social Sciences, version 22.0, for Windows (SPSS, Inc., Chicago, IL). Sociodemographic and clinical characteristics of participants are presented according to statin use (yes vs. no) and compared using Student's unpaired t-test and the chi-squared test for continuous and categorical variables, respectively. Univariate regression analyses, minimally adjusted for age, were performed to identify variables associated with statin use. Additional multiple logistic regression tests were run to identify independent determinants of statin use. A number of interaction terms (combinations of age, disability, cognitive impairment, polypharmacy, CHD, PAD, and cerebrovascular disease) were included in the multiple logistic regression analysis. We used backward elimination to omit factors and interactions that were not significantly associated with statin use. Statistical significance was set at two-sided p-values of ≤0.05.

Results

Among 2581 older adults who participated in the Italian HES 2008–2012, prevalent CV diseases were identified in 462 participants (17.9%). Of these, 70 were excluded because they had atrial fibrillation (n = 25) and/or gave no information on disability and/or did not undergo evaluation of cognitive function. Such 70 excluded participants had similar age (71.9 ± 4.5 years) and the prevalence of statin use (45.7%) when compared with those who were included. Finally, 392 participants (age 72.1 ± 4.4 years, 61.5% men) were studied. CHD was identified in 67.1% of participants, cerebrovascular disease in 23.5%, and PAD in 18.1%. Thirty-four subjects (8.7%) were diagnosed with more than one CV disease. One hundred ninety (49.0%) were statin users. The most frequent prescriptions were for simvastatin (48.4% of statin users), atorvastatin (24.2%), and rosuvastatin (10.0%). As shown in Table 1, statin users were more likely to be married and to have hypertension, diabetes, CHD, previous myocardial revascularization (i.e., PTCA and/or CABG), and, as expected, more favorable cholesterol levels. Use of aspirin, ACE inhibitors, and angiotensin receptor blockers was also higher in statin users. Conversely, they were less likely to be disabled and to have cognitive impairment. Participants with cerebrovascular disease and PAD were less likely to be prescribed with statins than CHD patients. With the exception of ACE inhibitors or angiotensin receptor blocker use, all the other variables whose prevalence was found to be different between groups were significantly associated with statin use, as shown by regression analyses adjusted for age (Table 1). Table 2 shows results of the logistic regression analysis. After backward elimination of nonsignificant variables, disability, cognitive impairment, and polypharmacy were found to predict statin nonuse, whereas having hypertension, diabetes, or previous myocardial revascularization predicted statin use. Although diagnoses of PAD or cerebrovascular disease were not found to predict statin use, significant interaction terms were observed between both of these and disability. A strong interaction term was found between disability and cognitive impairment in predicting statin underuse.

Table 1.

Characteristics of the Sample by Statin Use and Age-Adjusted Regression Analysis with Statin Use as the Dependent Variable

	Yes (n = 190)	No (n = 202)	P	Age-adjusted regression
	Yes (n = 190)	No (n = 202)	P	OR	95% CI
Age (years)	71.8 ± 4.4	72.4 ± 4.3	0.173	—	—
Men (%)	60.5	62.4	0.785	0.99	0.89–1.09
Married (%)	77.3	67.3	0.035	1.12	1.01–1.26^*
Low education (%)	49.5	55.4	0.279	0.95	0.86–1.05
Smoking habits (%)
Current	10.5	11.0	0.799	0.96	0.81–1.13
Former	38.0	34.6
Never	51.5	54.4
BMI, kg/m² (%)
<25	21.0	20.8	0.846	0.97	0.85–1.09
25–29.99	48.4	46.0
≥30	30.6	33.2
CV risk factors
Hypertension (%)	88.0	74.2	<0.001	1.25	1.10–1.41^**
Diabetes (%)	41.0	23.7	<0.001	1.04	1.03–1.05^**
Total cholesterol (mg/dL)	177.7 ± 36.8	187.2 ± 42.5	0.018	1.01	0.99–1.02
LDL cholesterol (mg/dL)	100.7 ± 35.0	124.5 ± 39.4	<0.001	1.02	1.01–1.04^**
HDL cholesterol (mg/dL)	53.7 ± 13.0	50.7 ± 13.7	0.027	1.00	0.98–1.02
CHD (%)	78.4	56.4	<0.001	1.30	1.17–1.43^***
Angina	32.1	30.7	0.848	1.02	0.92–1.14
Myocardial infarction	18.0	15.8	0.683	1.04	0.91–1.18
Revascularization	52.6	25.2	<0.001	1.36	1.23–1.50^***
Cerebrovascular disease (%)	19.0	27.7	0.054	0.88	0.78–0.98^*
Stroke	9.5	13.3	0.294	0.91	0.78–1.07
TIA	12.1	16.8	0.237	0.91	0.79–1.05
Peripheral artery disease (%)	13.7	22.3	0.041	0.87	0.76–0.98^*
COPD (%)	8.0	13.8	0.057	0.86	0.73–1.01
CKD (%)	20.5	20.8	0.952	1.00	0.88–1.13
Previous cancer (%)	2.6	3.4	0.853	0.83	0.66–1.04
Depression (%)	18.0	13.3	0.273	1.10	0.96–1.27
Geriatric assessment (%)
ADL/IADL disability	4.7	11.4	0.027	0.78	0.67–0.87^*
Mobility disability	4.7	15.3	<0.001	0.75	0.64–0.89^**
Any disability	8.4	22.8	<0.001	0.76	0.67–0.87^***
Cognitive impairment	9.5	19.0	0.013	0.82	0.71–0.98^**
Medications (%)
ACEi/ARB	50.5	39.6	0.038	1.04	1.00–1.09
β-Blockers	23.1	16.3	0.116	1.03	0.91–1.14
CCBs	19.5	13.0	0.101	1.03	0.90–1.16
Diuretics	26.3	22.3	0.415	1.00	0.90–1.09
Antithrombotic agents	40.0	35.6	0.432	1.01	0.91–1.10
Aspirin	38.0	27.7	0.041	1.05	1.01–1.10^*
Clopidogrel	6.8	6.0	0.874	1.00	0.93–1.07
Warfarin	4.2	4.4	0.897	1.00	0.92–1.09
NVKOAs	3.2	2.5	0.918	1.01	0.95–1.07
Digoxin	5.8	3.4	0.391	1.04	0.97–1.12
Nitrates	10.5	7.0	0.292	1.02	0.90–1.13
Antiarrhythmic	8.4	6.0	0.449	1.01	0.89–1.12
Insulin	10.7	8.4	0.435	1.01	0.96–1.08
Oral antidiabetics	24.2	22.8	0.829	1.00	0.89–1.12
Psychotropic drugs	14.2	17.3	0.480	1.01	0.93–1.08
Antiacid	21.6	14.8	0.110	1.03	0.97–1.10
Polypharmacy (%)	29.5	40.6	0.028	0.86	0.77–0.95^**

p < 0.05; ^** p < 0.01; ^*** p < 0.001.

ACEi, angiotensin-converting enzyme inhibitors; ADL, activities of daily living; ARBs, angiotensin receptor blockers; CCBs, calcium channel blockers; CHD, coronary heart disease; CI, confidence interval; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; IADL, instrumental activities of daily living; MMSE, Mini-Mental State Examination; NVKOAs, nonvitamin K oral anticoagulants; OR, odds ratio; TIA, transient ischemic attack.

Table 2.

Logistic Regression

	OR	95% CI	p
Any disability (yes vs. no)	0.81	0.71–0.92	0.002
Cognitive impairment (yes vs. no)	0.87	0.78–0.98	0.018
Polypharmacy (yes vs. no)	0.86	0.75–0.98	0.035
Hypertension (yes vs. no)	1.19	1.05–1.34	0.005
Diabetes (yes vs. no)	1.14	1.03–1.27	0.013
Myocardial revascularization (yes vs. no)	1.31	1.16–1.48	<0.001
Cerebrovascular disease × any disability	0.88	0.78–0.99	0.048
PAD × any disability	0.87	0.78–0.96	0.009
Any disability × cognitive impairment	0.80	0.69–0.96	0.007

Correlates of statin use and interactions. Due to collinearity between ADL/IADL and mobility, only disability was included.

PAD, peripheral artery disease.

Discussion

In this study conducted on a representative sample of the Italian older population, 65–79 years of age, we found that the prevalence of statin use in individuals with a diagnosis of atherosclerotic CV disease was 48.5%. Previous reports have documented low use of statins in older individuals,^4
–6 indicating that there is a substantial gap between guidelines and recommendations and clinician's attitude toward statin prescription in older adults. Remarkably, current guidelines recommend statin treatment for secondary CV prevention without posing age restrictions, indicating that also in individuals >75 years of age, at least a moderate-intensity statin therapy should be initiated.¹ This present study is one of the few ones that have assessed the prevalence of statin use for secondary prevention in a population-based sample of older adults. A study on a sample of patients hospitalized with first-time myocardial infarction found that in those who were already diagnosed with any atherosclerotic CV disease (n = 166, age 78.3 ± 9.4 years), only 34.5% were statin users on hospital admission.⁶ Similarly, results from the population-based PALM Registry have indicated that among 3425 individuals (60–84 years of age) in secondary prevention, those >75 years of age were significantly less likely to receive any statin, in particular high-intensity treatment.⁴ Results of other large, observational population-based studies, that is, the cross-sectional analysis of The Irish Longitudinal Study on Ageing²⁴ and the EUROASPIRE IV,²⁵ are less useful to provide reliable estimates of statin use for secondary prevention in the older population due to the wide range of age²⁵ or younger age of the sample,²⁴ lack of information on age-adjusted prevalence of statin use,²⁵ and lack of assessment of clinical and functional correlates of statin use.^24,25 Moreover, all studies have focused on CHD patients, providing no information on the secondary CV prevention population as a whole.^4,6,24,25 The more recent EUROASPIRE V survey provides more information on the older population by analyzing the proportion of lipid-lowering treatment use in 7732 CHD patients aged 18–80 years (66.2% aged ≥60 years) in the period after hospital discharge.²⁶ Authors showed that many older patients are left untreated or receive lower-intensity treatment. Notably, in the months following hospital discharge, 52.6% of participants had their lipid-lowering treatment interrupted or shifted to a lower intensity. Only in 15.8% there was a clear demonstration of treatment intolerability, mostly due to persistent muscular pain, whereas in a large proportion of participants (i.e., 36.8%), statin treatment was interrupted or reduced for physician's advice without a detailed explanation. Paradoxically, older participants had lower total and LDL cholesterol levels despite lesser treatment, probably due to age-related declines in cholesterol synthesis. Results of the EUROASPIRE V are limited by the lack of information on the prevalence of common geriatric conditions.²⁶ Thus, although such results give a reliable estimate of older patients receiving suboptimal secondary CV disease prevention, at least for CHD, it is not possible to identify social and biological correlates of treatment underuse. Results from another European cross-sectional survey on 969 community-dwelling older adults aged >70 years without proven established CV disease²⁷ indicate that there is a profound insufficient level of awareness and treatment of major CV risk factors, especially dyslipidemia, supporting the hypothesis that targeting adverse levels of major risk factors for CV disease in either primary or secondary prevention in older individuals might be not considered as important as in younger ages by physicians.¹⁰ The main findings of our study may be summarized as follows: (1) the prevalence of statin use is low among individuals aged 65–79 years with established CV disease; (2) subjects with PAD or cerebrovascular disease are less likely to receive statins when compared with CHD; and (3) common geriatric conditions, that is, functional disability, cognitive impairment, and polypharmacy, predict statin nonuse. The observed prevalence of statin use of 48.5% among individuals with established CV disease, and thus eligible for statin treatment, is by far lower than expected based on current guidelines.¹ We have observed that although participants not using statins were more likely to use ≥5 medications per day, they were less likely to use ACE inhibitors, angiotensin receptor blockers, and aspirin, which might indicate that statin nonusers have greater polypharmacy, likely due to greater non-CV comorbidity, and that they might be less likely to receive other evidence-based prescriptions for secondary CV prevention as well. Evidence of benefit of statins for secondary prevention in older adults mainly derives from three major trials demonstrating that high-intensity statin treatment was better than moderate-intensity treatment to reduce recurrent CV events.^28
–30 Although such trials included a relatively low proportion of individuals >75 years of age and none >80, there was sufficient evidence by subgroup analyses to recommend at least a moderate-intensity approach at any age.¹ Several factors might prevent clinicians to prescribe statins in older patients, such as poor evidence of benefit at older age, concerns about drug tolerability, and concerns about prescribing to patients who often carry other major competing risk factors for death, for example, physical frailty and disability. Very little evidence exists on benefits of statin use in real-world elderly populations. Two large studies have included comorbid and disabled older individuals.^8,9 A study on 12.156 individuals aged 76.5 ± 9.2 years at baseline with a diagnosis of myocardial infarction followed up for 10 years investigated the effectiveness of statin treatment to reduce recurrence of coronary events.⁸ The prevalence of polypharmacy, defined as use of >5 medications per day (60.5%), and high comorbidity burden, defined as a Charlson Index score ≥3 (36.3%), was as expected in typical elderly populations. The authors reported that statin use was associated with reduced 10-year recurrence of myocardial infarction in participants with baseline age 60–79 years (hazard ratio [HR] = 0.73, 95% confidence interval [CI] = 0.57–0.94), but not in those ≥80 years, after adjustment for competing risk factors for death. The other study, conducted on 184.156 older patients who survived a myocardial infarction followed up for 12 months⁹ showed that the higher the functional impairment at hospital discharge, the lower the probability of being prescribed with statins. Statin users had a lower risk of 12-month all-cause mortality than nonusers. Notably, there was sufficient sample size to test the effect in disabled individuals, with authors demonstrating that benefit was similar between individuals with and without functional impairment. Thus, results from these two studies support the evidence of the benefit of statin treatment for secondary prevention in older individuals, at least until 80 years of age, and that the effect on survival might also extend to disabled individuals. A further important finding of this study is that participants with a previous diagnosis of ischemic cerebrovascular disease or PAD were less likely to be statin users than those with CHD, especially those who underwent myocardial revascularization procedures. These findings are in line with those of previous reports. Two large cohort studies have shown high rates of statin discontinuation after an ischemic stroke.^11,12 In particular, a nationwide cohort study¹¹ has indicated that among 45.151 ischemic stroke patients evaluated in the initial period after stroke, that is, days 90 to 180, 7.0% of patients were on reduced statin therapy and 18.5% were no longer on statin therapy. Authors have emphasized the importance of statin continuation by demonstrating that discontinuation robustly increased the risk of 1-year recurrent stroke (HR = 1.42, 95% CI = 1.28–1.57). We have found that the prevalence of statin use was the lowest (29.67%) in participants with PAD. A cohort study assessing time trends in the prevalence of use of secondary preventive therapies in patients with PAD in the United Kingdom showed that although the prevalence of statin use has increased in recent years, a large proportion of subjects did not receive statin treatment in the 2 months following the diagnosis of PAD.¹⁴ Similarly, a follow-up study of a nationally representative cohort of PAD patients in the United States found that over a 8-year follow-up, only 33.1% received statin treatment.¹³ The authors also found that comorbid CHD significantly increased the likelihood of being prescribed. In our study, although the prevalence of statin use was significantly lower in participants with cerebrovascular disease and PAD, such conditions did not significantly predict statin use after multiple adjustments. This might be due to the relatively low proportion of participants diagnosed with these conditions, which might not allow sufficient statistical power. However, results allow hypothesizing that guideline-based secondary prevention in patients with cerebrovascular ischemic disease and PAD has not become a widely disseminated practice. We have also observed that systematic statin use might not hold true for CHD patients in general. In fact, by subgroup analyses, we have found that statin use was predicted by a previous myocardial revascularization procedure, that is, PTCA or CABG, and not by CHD per sè. Such finding might have several explanations. Patients who undergo revascularization might have suffered more severe coronary disease, for example, ST-segment elevation myocardial infarction, which may prompt clinicians to adopt stricter control of CV risk factors following diagnosis. In addition, subjects who are deemed eligible for coronary revascularization might have better health and functional status and thus might be more likely to be prescribed with evidence-based medications. An important finding of this study is that common geriatric conditions, that is, cognitive impairment and functional disability, independently associated with underuse of statins. Such finding is not surprising as former literature clearly indicates that older patients with CV disease and comorbid cognitive impairment are prescribed fewer evidence-based CV medications.³¹ We hypothesize that statin underuse in patients with dementia and disability is not explained by physician's nihilism or inertia toward older patients for the main reason that statin nonusers were found to be prescribed with more drugs than statin users. Probably, in the context of patients who need multiple prescriptions, physicians might consider statin treatment less important compared with other medication classes. Our study has limitations. The cross-sectional nature of the analysis does not allow implying causality. Furthermore, we are not aware of the statin dose assumed, thus we cannot estimate statin treatment intensity in statin users. We are not aware whether there were former users among statin nonusers and if there had been any, we could not understand the reason for statin discontinuation. However, the major aim of this study was to provide a picture of statin use in patients with overt CV disease, and even so, we can reliably estimate the prevalence of nonoptimal secondary CV prevention. Another issue is that the response rate of 48.4% of those aged ≥65 years might introduce a bias as these subjects might be healthier or sicker than the rest of the population. If the subjects were sicker, the prevalence of statin use might be underestimated, whereas if they were healthier, it might be overestimated. A further limitation is the lack of a validated frailty measure. However, the fact that conditions such as polypharmacy and mobility disability, which can be considered proxies of frailty, robustly predicted statin nonuse allows to hypothesize that physical frailty per sè might represent a barrier for statin prescription. Strengths of the study include its population-based sample of relatively large size, objective assessment of CV diseases and measurement of CV risk factors according to standardized procedures, availability of rich confounder information, and a comprehensive geriatric assessment. In conclusion, our data suggest important barriers to the uniform and widespread use of statins for secondary CV prevention in older adults. Suboptimal secondary CV prevention is a major concern as CV events in old age bring a huge burden of disability.¹⁵ Such findings support the need to promote awareness and education for the medical community. As the population ages, the number of elderly individuals who survive a CV event will increase further. Further studies are needed to better establish the benefits and risks of statins for secondary prevention in old age, in particular in the oldest individuals, who represent the fastest growing segment of the population. Beyond the effects on CV morbidity and mortality, there is an urgent need to understand whether statin treatment might reduce the risk of disability in older patients with CV disease. Physicians and CV guidelines are required to make the effort to address the goal of preventing or postponing functional decline in patients with CV disease.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding sources for this work.

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