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This chapter addresses the following Geriatric Fellowship Curriculum Milestone: #9

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LEARNING OBJECTIVES

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Learning Objectives

  • Describe changes in lipoproteins with aging and their mechanisms and impact on cardiovascular disease.

  • Review the therapeutic options to address dyslipidemia.

  • Address special considerations germane among older individuals.

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Key Clinical Points

  1. Total cholesterol, low-density lipoprotein cholesterol (LDL-C), and triglyceride (TG) concentrations increase in both men and women from the third to seventh or eighth decades of life, with more pronounced increase in LDL-C concentration in women and important changes in lipoprotein classes of women at menopause. Typically, there is a decline in LDL-C and total cholesterol concentration in oldest age cohorts.

  2. Dyslipidemia is a well-established risk factor for cardiovascular disease in older adults age 60 to 80 years. However, there are limited data in patients above the age of 80.

  3. Current recommendations for screening and treatment of dyslipidemia that employ risk-based algorithms represent a fundamental change in the approach to cardiovascular disease management. Using this approach, potentially millions of adults over the age of 75 are candidates for statin therapy based solely on their age. We advocate a more measured patient-centric approach where the patient and clinician together discuss individual treatment preferences and goals of care.

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INTRODUCTION

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Dyslipoproteinemia encompasses a range of disorders of lipoprotein metabolism that include both abnormally high and low lipoprotein concentrations, as well as abnormalities in the composition of the lipoprotein particles. Dyslipoproteinemias are clinically relevant in older adults primarily due to their role in the pathogenesis of atherosclerotic cardiovascular disease (ASCVD), which includes coronary heart disease (CHD), cerebrovascular disease, peripheral arterial disease (PAD), and chronic renal disease. Older patients account for greater than 75% of total cardiovascular disease (CVD) mortality and 50% of all acute myocardial infarctions (MIs) in the United States. Although CVD morbidity and mortality have declined over recent decades, the percent reduction of CVD events is nearly 50% less in older patient groups. Dyslipidemia is a risk factor for ASCVD in older adults aged 60 to 80, and strong outcome data support pharmacologic therapy in this age group; however, the data are more limited among those above 80 years.

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The American College of Cardiology (ACC)/American Heart Association (AHA) Task Force on Practice Guidelines issued new guidelines in 2013 for the management of dyslipidemia in adults. These guidelines have explicit treatment recommendations for adults across the age span based on the presence or absence of clinical ASCVD, and the use of pooled cohort equations to estimate the 10-year risk of developing ASCVD. These guidelines make stringent recommendations for patients with CHD equivalents such as diabetes and renal disease, and for other high-risk individuals with multiple CVD risk factors. The guidelines highlight that heart-healthy lifestyle habits should be encouraged for all individuals. In addition, they emphasize the use of statins to treat dyslipidemia and reduce ASCVD risk. The recommendations for statin therapy for individuals at elevated absolute ...

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