High Cholesterol Less Risky for the Elderly, Study Finds : Health: Researchers recommend that doctors stop therapies for lowering levels in those older than 75. Treatment of younger people is still important, they say.
High cholesterol levels in the elderly pose little or no danger, according to a new study by researchers who recommend that physicians discontinue screening and cholesterol-lowering therapies among people over age 75.
The report, in today’s Journal of the American Medical Assn., finds no link between high cholesterol levels and an increased risk of heart attack in a study of 997 people, ages 71 to 102, living in New Haven, Conn.
Yale University researchers measured blood cholesterol levels throughout the course of the four-year study and compared them to the rates of hospitalization or death from heart attacks and other causes, finding no correlations. Although the results seem to fly in the face of conventional wisdom, they confirm results from a little-noted University of Washington study reported last year.
The Yale researchers, and two UC San Francisco physicians who wrote an accompanying editorial, emphasize that both screening and treatment remain very important for reducing the risk of heart attacks among younger people, even those in their late 60s and early 70s.
But they argue that special diets may be disruptive to lifestyle, that medication designed to lower cholesterol has side effects, and that lowering cholesterol can actually increase the risk of death from other causes.
The researchers suggest that two factors may be responsible for cholesterol’s apparently benign effect in old age: Those who are most susceptible to high cholesterol may die before age 75, or aging of the blood vessels may somehow make them more resistant to the effects of cholesterol.
“There is no compelling evidence that cholesterol is an important risk factor for heart disease in the elderly, and there is even less evidence that lowering cholesterol is beneficial,” said Dr. Harlan M. Krumholz, who headed the Yale study. “It seems appropriate to adopt a conservative stance of not treating high cholesterol” in such patients. “We should focus more on controlling high blood pressure and smoking, which are significant risk factors.”
“I think this is good news for older people,” said Dr. Stephen B. Hulley of UC San Francisco, co-author of the editorial. “In general, we don’t like to treat healthy people in any way. We don’t like to label them, tell them to alter their diet or use drugs unless there is direct evidence that it is more beneficial than harmful.” Such evidence is not available for cholesterol-lowering drugs, he added.
A dissenting view was offered by Dr. James Cleeman, coordinator of the National Cholesterol Education Program at the National Heart, Lung and Blood Institute. “It is true that cholesterol is a less-powerful risk factor in the elderly than in the middle-aged, but there is much more coronary disease in the elderly, many more heart attacks,” he said. “There is a great deal of evidence to suggest that the elderly should not be excluded from the benefits of cholesterol lowering.”
Although all the researchers agreed that the elderly should follow a “prudent diet” because of the effects of fats and cholesterol on other diseases, many expressed concern about cholesterol-lowering drugs, which can have adverse side effects, such as kidney damage. Some studies have also shown that low cholesterol levels may be linked to homicides, suicides, strokes, certain cancers, liver disease and lung disease.
Epidemiologist Richard A. Kronmal of the University of Washington, author of the earlier study, said: “We shouldn’t be treating people without good evidence that the drugs work. . . . Any medication has risks, and they could be higher in the elderly. What’s really needed is a clinical trial” to determine if drugs do provide a benefit.
The institute is in fact planning such a trial, but results are not expected to be available until 2002 at the earliest. Both sides agree that results from such a trial will help physicians advise patients. “Once we have that data, we’ll be in a position to make policy,” Cleeman said. But until then, Kronmal added, “It doesn’t seem prudent to treat people.”
According to the National Health and Nutrition Examination Survey, nearly one-third of people over the age of 75 have high cholesterol levels--greater than 240 milligrams per one-tenth of a liter of blood--that make them candidates for therapy under existing guidelines. Already, Hulley noted, 2 million elderly are receiving drug treatment and the number is rising.
Several previous studies have examined the relationship between cholesterol levels and the risk of heart disease, and the findings have been mixed. Typically, however, those studies have been smaller and have focused on only one ethnic group or sex. Krumholz’s study, in contrast, features “a heterogeneous group representing the diversity of urban society.”
The subjects had an average age of 79 when the study began. High cholesterol levels were not associated with hospitalization, incidence of heart attacks or other cardiovascular disease or deaths from any cause. The researchers also found no links to the ratio of HDL (“good cholesterol”) to LDL (“bad”). The study group did not, however, include any people who had already had a heart attack.
In addition to being generally less susceptible to cholesterol’s effects, survivors in their 70s may also experience normal alterations in blood vessels that make it more difficult for atherosclerotic plaque caused by cholesterol to clog the vessels, the scientists said.
Krumholz conceded that “it is premature to say that the results are definitive, but they add to a growing body of evidence which suggests that high cholesterol is not as important a risk factor for older people as it is for younger.”
Combining results of this study with those from the Washington study, Hulley and Dr. Thomas B. Newman of UC San Francisco concluded that screening and treatment are inappropriate for most people over 75.
