Statins in older adults: benefits and risks

Do statins benefit older adults?

Statins lower LDL cholesterol and can reduce heart attacks, ischemic strokes, and other cardiovascular events, but their value in an older person depends more on individual risk than on age alone. In the Cholesterol Treatment Trialists’ Collaboration meta-analysis, every 1 mmol/L reduction in LDL — about 38.7 mg/dL — was associated with a 21% proportional reduction in major vascular events. Benefits were seen across age groups and remained consistent among people with pre-existing vascular disease¹. However, only 14,483 of 186,854 participants, or 8%, were older than 75, illustrating the historical underrepresentation of this age group¹. The key question is therefore not simply “Is this person over 75?” but “What is their cardiovascular risk, functional status, life expectancy, and treatment priority?”. Chronological age alone is not a sound reason to start, deny, or automatically discontinue a statin^2,3.

What is the difference between primary and secondary prevention?

The case for statin treatment is generally stronger in secondary prevention than in primary prevention. Secondary prevention applies to people who have already had atherosclerotic cardiovascular disease, such as a myocardial infarction, ischemic stroke, peripheral artery disease, angioplasty, stenting, or bypass surgery. Evidence supporting LDL reduction is more consistent in this setting, including after age 75^2,4,3,1. Following a heart attack, Brazil’s Ministry of Health protocol recommends starting statin treatment early when there is no contraindication and regardless of the initial LDL level; intensity, medicine, and dose should be defined individually by the physician according to treatment goals, age, kidney and liver function, interactions, and tolerability⁴. Primary prevention means treatment before a first cardiovascular event. Here, the decision should reflect absolute risk based on blood pressure, smoking, diabetes, kidney disease, LDL, family history, subclinical atherosclerosis, frailty, life expectancy, and patient preferences^2,3,5. For apparently healthy adults aged 70 or older, the 2025 European update uses SCORE2-OP to estimate the 10-year risk of heart attack, ischemic stroke, or cardiovascular death⁵. If uncertainty remains, a coronary artery calcium score or imaging evidence of atherosclerosis may refine the assessment. No or minimal coronary calcium may support not starting treatment when interpreted within the full clinical picture^3,5.

What did the STAREE trial add to primary prevention?

The preliminary STAREE results suggest that relatively healthy older adults without clinical cardiovascular disease may experience fewer cardiovascular events with atorvastatin, but they do not establish a universal recommendation. The trial randomized 9,971 community-dwelling adults aged at least 70; their mean age was 74.7 years, and 52% were women. Participants had no clinical cardiovascular disease, diabetes, or dementia and received atorvastatin 40 mg daily or placebo; this dose describes the research protocol only and is not dosing advice for readers⁶. Over a median 5.9 years, the composite of cardiovascular death, nonfatal heart attack, stroke, or revascularization occurred in 6.0% of the atorvastatin group and 8.3% of the placebo group. The congress communication reported a hazard ratio of 0.72, with a 95% confidence interval of 0.62 to 0.83, corresponding to an approximately 28% relative reduction that was rounded to 30% in the announcement. The observed crude difference was 2.3 percentage points; approximately 44 people treated for about six years to prevent one composite event is an estimated NNT derived from that absolute difference and applies to the study population and follow-up period⁶. Atorvastatin did not produce a statistically conclusive difference in disability-free survival: death, dementia, or persistent physical disability occurred in 12.8% versus 13.6%⁶. The available source is an ESC Congress communication dated August 29, 2025, together with the trial registry, rather than a full peer-reviewed article; the findings should therefore be considered preliminary until complete publication. The 2025 Brazilian guideline and 2025 NLA/AGS expert clinical consensus preceded that communication, while the 2025 ESC/EAS update was released during the same congress cycle; no chronological comparison should imply that these documents had already assessed a complete STAREE publication^2,3,5,6. The US document³ is the National Lipid Association and American Geriatrics Society expert clinical consensus titled “Managing Hypercholesterolemia in Adults Older Than 75 Years Without a History of Atherosclerotic Cardiovascular Disease,” not a universal 2026 US guideline. It states that discussing a moderate-intensity statin may be reasonable for primary prevention after age 75 when estimated life expectancy is at least 2.5 years and after individual assessment of benefits, risks, and preferences; this is conditional consensus guidance³. STAREE did not adequately represent frail or institutionalized patients or those with diabetes, dementia, multiple serious illnesses, or limited life expectancy, so it does not fully answer how these groups should be treated⁶.

What side effects should be considered?

Most people tolerate statins, but symptoms and metabolic changes deserve a careful clinical assessment. In a meta-analysis of 19 double-blind trials, muscle pain or weakness was reported by 27.1% of statin recipients and 26.6% of placebo recipients. During the first treatment year, about 11 additional episodes per 1,000 person-years were attributable to the statin⁷. This does not mean that muscle pain is imaginary: osteoarthritis, hypothyroidism, exercise, low muscle mass, other illnesses, and other medicines can produce similar symptoms. The 2025 Brazilian Dyslipidemia and Atherosclerosis Prevention Guideline notes that statin-related symptoms often emerge within 4 to 12 weeks and may involve bilateral, proximal pain, weakness, or cramps. Intolerable symptoms warrant evaluation of creatine kinase, alternative causes, and drug interactions². Statin intolerance should not be diagnosed after one attempt; options include a lower dose, a different statin, altered dosing frequency, or combination with another lipid-lowering medicine². Low- or moderate-intensity statins produced a 10% proportional increase in new diabetes diagnoses — 1.3% per year versus 1.2% with placebo — while high-intensity therapy produced a 36% proportional increase. Absolute rates from these study groups should not be compared directly because glucose testing differed⁸. Average increases in glucose and glycated hemoglobin were small, and 62% of new cases occurred in participants already near the diagnostic threshold⁸. Reviews of randomized trials have not demonstrated that statins prevent dementia or cognitive decline; these data also have limited representation of very old, frail adults or people with established dementia⁹. Statins should not be offered with a promise that they will prevent dementia or preserve independence^6,9.

How do dose, polypharmacy, and frailty affect treatment?

There is no single atorvastatin or statin dose that is appropriate for every older adult. STAREE tested atorvastatin 40 mg as a research protocol in relatively healthy adults receiving primary prevention; outside the trial, including after a heart attack, intensity and dose must be individualized by the physician, and the US consensus provides only conditional guidance for primary prevention after age 75^4,3,6. The choice should account for the desired LDL reduction, kidney and liver function, body mass, hypothyroidism, frailty, tolerability, and potential interactions. Older adults are more likely to use several medicines and may receive temporary treatments during hospital stays, travel, or urgent care. Before starting or intensifying a statin, it is essential to review all prescription medicines, over-the-counter products, and supplements^2,3. An interaction may justify a lower dose, a different statin, or closer monitoring without necessarily requiring permanent abandonment of therapy. Treatment intensity can also be adjusted according to LDL response and symptoms. The public STAREE communication reported 2.7% in each group for a category labeled “serious adverse events,” based on participants in each arm over a median follow-up of 5.9 years; this was not an annual rate. Because the summary did not provide counts, full adjudication criteria, or enough detail to distinguish all serious events from events considered treatment-related, this percentage should not be interpreted as the cumulative incidence of every serious medical event. The summary also indicated that musculoskeletal, hepatobiliary, and diabetes-related categories were more frequent with atorvastatin but did not publish separate rates; classification and denominators should be confirmed in the full peer-reviewed report⁶.

When should a statin be started, continued, or reconsidered?

Established cardiovascular disease, a previous cardiovascular event, very high LDL, and high absolute cardiovascular risk generally favor starting or continuing statin therapy. Diabetes, kidney disease, multiple risk factors, imaging evidence of atherosclerosis, meaningful coronary calcium, good functional status, and enough life expectancy for benefits to emerge may further support treatment^2,4,3,5,1. Greater caution is appropriate with advanced frailty, terminal illness, active liver disease, major functional decline, problematic polypharmacy, important drug interactions, significant muscle symptoms, or a preference to reduce preventive medication burden^2,3. The NLA/AGS consensus recommends discussing the start, continuation, or withdrawal of treatment in light of cardiovascular risk, multimorbidity, frailty, function, polypharmacy, life expectancy, and personal priorities rather than chronological age alone³. The document identifies a life expectancy of less than one year as a circumstance in which withdrawal of lipid-lowering treatment may be considered to reduce medication burden and potential adverse effects, particularly in the setting of life-limiting illness. This is conditional consensus guidance, not a mandatory cutoff or authorization to stop treatment without medical advice, particularly in secondary prevention³.

How can patients and clinicians make a shared decision?

A sound decision combines scientific evidence, cardiovascular risk, overall health, and the patient’s own priorities. Useful questions include: “Has there already been a heart attack, stroke, peripheral artery disease, or revascularization?”, “What is the absolute risk of a first event?”, “Are frailty, interactions, or possible treatment-related symptoms present?”, “How long would treatment be needed before benefit is likely?”, and “How important is this risk reduction compared with the person’s other goals?”. A clinical assessment should also consider whether symptoms appeared after treatment began or the dose changed, whether another cause is more likely, and whether the regimen can be adjusted instead of simply giving up cardiovascular protection. Do not start, change the dose of, or stop a statin without an individual evaluation, because the same approach may be appropriate for one person and unsuitable for another. References:² Brazilian Society of Cardiology. Diretriz Brasileira de Dislipidemias e Prevenção da Aterosclerose – 2025. Arquivos Brasileiros de Cardiologia. 2025. URL: https://abccardiol.org/article/diretriz-brasileira-de-dislipidemias-e-prevencao-da-aterosclerose-2025/. Accessed September 15, 2025.⁴ Brazil. Ministry of Health; National Committee for Health Technology Incorporation. Protocolo Clínico e Diretrizes Terapêuticas das Síndromes Coronarianas Agudas. Brasília, DF: Ministry of Health; 2023. URL: https://www.gov.br/conitec/pt-br/midias/protocolos/pcdt-sindromes-coronarianas-agudas.pdf. Accessed September 15, 2025.³ National Lipid Association; American Geriatrics Society. Managing Hypercholesterolemia in Adults Older Than 75 Years Without a History of Atherosclerotic Cardiovascular Disease: An Expert Clinical Consensus from the National Lipid Association and the American Geriatrics Society. Journal of Clinical Lipidology. 2025. URL: https://pubmed.ncbi.nlm.nih.gov/?term=%22Managing+Hypercholesterolemia+in+Adults+Older+Than+75+Years%22. Accessed September 15, 2025.⁵ European Society of Cardiology; European Atherosclerosis Society. 2025 Focused Update of the 2019 ESC/EAS Guidelines for the Management of Dyslipidaemias. European Heart Journal. 2025. URL: https://www.escardio.org/Clinical-Practice-Guidelines/2025-Focused-Update-of-the-2019-ESC-EAS-Guidelines-for-the-management-of-dyslipidaemias. Accessed September 15, 2025.⁶ European Society of Cardiology; STAREE investigators. STAREE — STAtins in Reducing Events in the Elderly: results presentation. ESC Congress 2025; communication dated August 29, 2025. Trial registration: ClinicalTrials.gov NCT02099123. URLs: https://www.escardio.org/The-ESC/Press-Office/Press-releases and https://clinicaltrials.gov/study/NCT02099123. Accessed September 15, 2025. Available as a congress communication and trial registry, with no full peer-reviewed publication identified in the cited source.⁷ Cholesterol Treatment Trialists’ Collaboration. Effect of Statin Therapy on Muscle Symptoms: An Individual Participant Data Meta-analysis of Large-scale, Randomised, Double-blind Trials. The Lancet. 2022;400:832–845. DOI: https://doi.org/10.1016/S0140-6736(22)01545-8.⁸ Cholesterol Treatment Trialists’ Collaboration. Effects of Statin Therapy on Diagnoses of New-onset Diabetes and Worsening Glycaemia in Large-scale Randomised Blinded Statin Trials: An Individual Participant Data Meta-analysis. The Lancet Diabetes & Endocrinology. 2024;12:306–319. DOI: https://doi.org/10.1016/S2213-8587(24)00040-8.¹ Cholesterol Treatment Trialists’ Collaboration. Efficacy and Safety of Statin Therapy in Older People: A Meta-analysis of Individual Participant Data from 28 Randomised Controlled Trials. The Lancet. 2019;393:407–415. DOI: https://doi.org/10.1016/S0140-6736(18)31942-1.⁹ McGuinness B, Craig D, Bullock R, Passmore P. Statins for the Prevention of Dementia. Cochrane Database of Systematic Reviews. 2016;1:CD003160. DOI: https://doi.org/10.1002/14651858.CD003160.pub3. Notice: this content is for informational and educational purposes only and does not replace an individual medical consultation, diagnosis, or medical advice.