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COMMENTARIES |
Department of Community and Preventive Medicine, University of Rochester School of Medicine and Dentistry, New York.
Address correspondence to Deborah R. Levy, MD, Department of Community & Preventive Medicine, 601 Elmwood Avenue, Box 644, Rochester, NY 14607. E-mail: deborah_levy{at}urmc.rochester.edu
We commend Aronow's desire to increase the amount of attention paid to cholesterol management in elderly patients, with the aim of maximizing the therapeutic benefit for this important cohort (1,2).
Patients older than age 65 years certainly have an increased absolute risk of cardiovascular disease (CVD) events (3). Current evidence and guidelines support treating elderly patients with equal rigor as younger cohorts (4–6). However, the National Health and Nutrition Examination Survey 1999–2000 (NHANES 99-00) (7) provides evidence that patients older than age 65 are not being treated according to these recommendations. Sixty percent of U.S. men and 77% of U.S. women between the ages of 65 and 74 years have a total cholesterol 
200 mg/dL. Furthermore, NHANES 99-00 reported that, among patients older than age 65 years, only 56% were aware of their diagnosis, and no more than 30% of those patients were receiving cholesterol-lowering medication. An even-fewer 18% of those being treated had a total cholesterol level below 200 mg/dL. This suggests a large treatment gap between the diagnosis and management of lipid disorders in elderly people. Dyslipidemia treatments can become a challenge for older patients, who are faced with polypharmacy, drug interactions, potential drug side effects, and complex medication regimens, which impede compliance (4). One might therefore question focusing on lowering current low-density lipoprotein (LDL) treatment targets, with the expressed awareness that current well-supported guidelines are not being met.
Recently, the National Cholesterol Education Program (NCEP) has recommended lower targets of LDL cholesterol for high-risk individuals (5). Current evidence does support aggressive lipid modification in elderly patients at high-risk for coronary disease events (6,8–10). The available evidence at this time, however, does not suggest differential treatment of geriatric cohorts, in terms of LDL targets. Nor does the clinical trial literature delineate that the cut-off of 70 mg/dL has been associated with improved outcomes specifically in elderly patients in clinical trials. Hopefully, the three large clinical trials currently in their final stages (TNT, SEARCH, and IDEAL) will have sufficient numbers of elderly patients without CHD to confirm that this important subgroup be treated with similar or greater benefit as all high-risk patients.
References
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