Dyslipidemia in the Elderly

Dyslipidemia is defined as the elevation of total cholesterol (TC), low density lipoprotein cholesterol (LDL-C), triglycerides, or lipoprotein(a) levels > 90th percentile or high-density lipoprotein cholesterol (HDL-C) or apo A-1 levels < 10th percentile. The prevalence of dyslipidemia depends on the population and its definition. Serum cholesterol is the major and most modifiable risk factor for atherosclerotic cardiovascular disease (ASCVD), which remains true in patients > 65 years old. Triglyceride-rich lipoproteins and low HDL-C are also related to ASCVD. Lifestyle modification, pharmacotherapy (lipid-lowering agents), and controlling other risk factors are critical components of primary and secondary preventative strategies to reduce ASCVD events. The number of individuals who benefit from lipid-lowering therapy increases with age. Statins are the primary group of drugs to prevent ASCVD events and decrease mortality. The main evidence in the elderly derives from many large-scale and well-conducted secondary prevention trials. Statin use for primary prevention in older adults aged 75 years old is not conclusive. Statins are associated with multiple side effects that should be balanced with the benefits in the older population. Ezetimibe is a safe lipid-lowering drug that, used in combination with a statin, can reduce cholesterol to desired levels. Inhibitors of PCSK9 prevent the LDL receptor from destruction, reduce LDL-C by 50%-60%, and are used in patients at very high risk of ASCVD and in primary severe hypercholesterolemia. Regarding triglycerides, fenofibrate has been used for many years; however, no evidence demonstrates a decrease in CV events. A recent FDA-approved drug for reducing triglycerides named eicosapentaenoic acid appears to decrease the residual risk of ASCVD events in selected patients on statins.