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REFLECTIONS
Dyslipidaemia
Dyslipidaemia Global Newsletter #9 2025

For risk assessment, the consensus highlights limitations of particularly in those with pre-existing risk factors, this risk is
traditional tools like PCEs for adults over 75, due to small outweighed by the reductions in major cardiovascular events.
numbers of older adults in their derivation cohorts and lack of Furthermore, literature suggests neutral or even protective
Dyslipidaemia
adjustment for competing risks. Competing risk-adjusted models statin-related cognitive effects in older adults. For deprescribing
are recommended and emphasis is placed on the utility of CAC statins, while observational data indicate an increased risk
scoring to refine risk stratification. A CAC score of zero indicates of cardiovascular events upon discontinuation in primary
a very low ASCVD event rate and overall mortality, making it prevention patients, discontinuing statins may be reasonable
reasonable to withhold statin therapy for primary prevention. for patients with life-limiting illnesses and limited life expectancy
Conversely, a CAC score of ≥100 identifies a higher-risk (less than one year), as it shows no difference in short-term
subgroup, for whom shared decision-making regarding statin survival or cardiovascular events, and can improve quality of life
initiation may be appropriate, even with limited RCT evidence and reduce medication costs.
in this specific context. Lifestyle modifications, including a
heart-healthy diet and physical activity, remain first-line therapy For non-statin therapies, the consensus points to the
regardless of risk assessment. Ezetimibe Lipid-Lowering Trial on Prevention of Atherosclerotic
Cardiovascular Disease in 75 or Older (EWTOPIA 75), which
When it comes to statin therapy, while observational studies demonstrated a significant reduction in MACEs with ezetimibe in
from territories like Hong Kong suggest statins are associated adults 75 years or older without coronary artery disease, making
with absolute risk reductions in CVD incidence, RCT data in the it a viable option if statins are not tolerated or are otherwise
primary prevention setting for adults over 75 remains limited, not advised. Bempedoic acid may also be considered in statin-
with some meta-analyses showing attenuated benefits in those intolerant patients over 75 based on subgroup analyses of the
without prior vascular disease. Analyses indicate that the risk of CLEAR Trial (Bempedoic Acid and Cardiovascular Outcomes
statin-associated muscle symptoms (SAMS) is not increased in in Statin-Intolerant Patients). However, there is insufficient
older adults and is often attributed to a nocebo effect. Although evidence to recommend PCSK9 inhibitors for primary prevention
statins are associated with a small increase in new-onset T2DM, in this population.

Managing hypercholesterolemia in primary prevention patients
older than 75 years, with LDL-C 70–189 mg/dL

ASCVD, atherosclerotic cardiovascular disease; CAC, coronary artery calcium; LDL-C, low-density lipoprotein cholesterol.

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