Kevin O’Connor, MD

Lefeber GJ, Knol W, Souverein PC, Bouvy ML, de Boer A, Koek HL. Statins After Ischemic Stroke in the Oldest: A Cohort Study Using the Clinical Practice Research Datalink Database. Stroke. 2021;52:1244–1252.

Statins are a component of usual care following ischemic stroke, but evidence for their initiation in patients age >80-years is limited. Lefeber et al. conducted an observational cohort study to examine the effect of statin initiation on recurrence of cardiovascular events and mortality in those age >80-years following a first stroke. They performed the same analyses on patients aged 65-80 for comparison.

Patients ≥80 and 65-80 had reductions in cardiovascular events when prescribed statins for > 2 years (≥80 adjusted HR, 0.70 [95% CI, 0.52–0.92]; 65-80 adjusted HR, 0.67 [95% CI, 0.49–0.91]) compared to no statin use. There was no significant difference in event rates for either cohort when treated for 1-2 years compared to untreated patients (≥80 adjusted HR, 0.79 [95% CI, 0.59–1.07]; 65-80 adjusted HR, 1.00 [95% CI, 0.69–1.46]). Using a statin for less than one year was associated with reductions in both groups (≥80 adjusted HR, 0.43 [95% CI, 0.29–0.41]; 65-80 adjusted HR, 0.43 [95% CI, 0.34–0.54]). Compared to < 2 years of statin use (or no use), there was a nonsignificant trend toward lower risk for the ≥80 cohort (adjusted HR, 0.80 [95% CI, 0.62–1.02]) and a significant reduction in the 65-80 group (adjusted HR, 0.74 [95% CI, 0.57–0.96]) with use >2 years. Adjusted for mortality, the NNT to reduce cardiovascular events in the ≥80 group and the 65-80 group were 48.8 and 68, respectively.

Statin use > 2 years was associated with reduced all-cause mortality for those ≥80 (adjusted HR, 0.59 [95% CI, 0.49–0.72]), but not in the 65-80 cohort (adjusted HR, 0.85 [95% CI, 0.67–1.08]). Both groups had a reduction with 1-2 years of statin use (≥80 adjusted HR, 0.71 [95% CI, 0.57–0.88]; 65-80 adjusted HR, 0.71 [95% CI, 0.52–0.96]) and <1 year of use (≥80 adjusted HR, 0.54 [95% CI, 0.46–0.63]; 65-80 adjusted HR, 0.63 [95% CI, 0.51–0.79]). In contrast to cardiovascular event reduction, >2 years of statin use reduced all-cause mortality compared to <2 years of use (including no use) for the ≥80 group (adjusted HR, 0.67 [95% CI, 0.57–0.80]), but not the 65-80 group (adjusted HR, 0.93 [95% CI, 0.76–1.13]). The mortality-adjusted NNT for all-cause mortality was much lower for patients ≥80 (14.8) compared to patients 65-80 (177.1).

These data suggest that it may be beneficial to initiate statins in patients age ≥80 years who had a first stroke. Additional investigation is needed to determine if this benefit is agent or dose dependent, as this was not evaluated in the study.