Patient 1 is a 77-year-old White man. At a routine follow-up visit, laboratory testing shows an elevated low-density lipoprotein cholesterol (LDL-C) level of 165 mg/dL (target < 100 mg/dL).1 He has no established atherosclerotic cardiovascular disease. The patient is functionally independent and has no limitations in basic or instrumental activities of daily living and no geriatric syndromes. He does not have hypertension, has no history of diabetes mellitus, is a nonsmoker, and is not taking aspirin or lipid-lowering medications. He has a body mass index of 20 kg/m2. His calculated 10-year atherosclerotic cardiovascular disease risk is approximately 22%. His estimated life expectancy is about 7 years.2
Patient 2 is also a 77-year-old White man presenting for routine follow-up with an LDL-C of 165 mg/dL and no atherosclerotic cardiovascular disease. He has multiple comorbidities, including type 2 diabetes mellitus, chronic kidney disease, advanced dementia, and uncontrolled hypertension. He has had recurrent falls in the past year, one resulting in a fracture. The patient requires assistance with instrumental activities of daily living. He is taking multiple medications, including antihypertensive drugs, insulin, donepezil, and quetiapine for behavioral manifestations of dementia. His body mass index is 30 kg/m2. He is a current smoker with a smoking history of 50 pack-years and is not taking aspirin or statins. His 10-year atherosclerotic cardiovascular disease risk is approximately 40%. His estimated life expectancy is approximately 2 years.2
Are these patients candidates for statin therapy for primary prevention of cardiovascular disease?
Yes and no. The patients are the same age and race. (Race is specified here because it is a required input variable in the pooled cohort equation used to estimate 10-year atherosclerotic cardiovascular disease risk.) However, patient 1 has preserved functional status and considerable life expectancy. Moderate-intensity statin therapy is appropriate for primary prevention of atherosclerotic cardiovascular disease, and age alone should not exclude him from treatment.
Patient 2, although chronologically the same age as patient 1, has a markedly different clinical profile. He has several geriatric syndromes, including cognitive impairment, recurrent falls, frailty, polypharmacy, and functional impairment, and has limited life expectancy. He is not a candidate for statin therapy.
WHAT IS THE EVIDENCE?
Trials and meta-analyses show that statins reduce cardiovascular events in adults age 65 and older who do not have cardiovascular disease (Table 1).3–6 Evidence is more limited in patients older than 80; in this group, most available data are derived from subgroup analyses and meta-analyses rather than randomized trials specifically designed for octogenarians.
Key evidence for statin therapy for primary prevention of atherosclerotic cardiovascular disease in older adults
In the Cholesterol Treatment Trialists’ (CTT) Collaboration meta-analysis3 of 28 randomized trials of statin therapy (> 186,000 participants), each 1-mmol/L (approximately 39 mg/dL) reduction in LDL-C was associated with a 25% relative reduction in major vascular events. The benefit was similarly proportional across age groups, including those older than 65. In primary prevention, this corresponded to an absolute risk reduction of 1.3% over 5 years (number needed to treat [NNT] 77).3
These findings were corroborated by large trials enrolling adults older than 65 without atherosclerotic cardiovascular disease. An analysis4 of the JUPITER (Justification for the Use of Statins in Prevention) trial5 concluded that rosuvastatin 20 mg daily reduced major cardiovascular events in participants age 70 and older by about 39%, yielding an absolute reduction of 0.77 events per 100 person-years (NNT 65 over 2 years) without a significant mortality benefit.4 Importantly, the analysis did not demonstrate a significant increase in adverse events in older participants receiving statin therapy.4
While statins reduce nonfatal cardiovascular events in older adults without cardiovascular disease, mortality benefit in primary prevention has not been seen in most studies. The clinical benefit may take several years to accrue (time-to-benefit), underscoring the importance of considering life expectancy and competing health risks when starting statin therapy in geriatric patients.3
WHAT DO GUIDELINES RECOMMEND?
The National Lipid Association and American Geriatrics Society expert clinical consensus7 from 2025 reflects the latest available evidence. It affirms that elevated LDL-C remains independently associated with increased incidence of atherosclerotic cardiovascular disease even in adults over age 75, with absolute risk of cardiovascular disease increasing substantially with advancing age. Acknowledging the limited specificity of traditional atherosclerotic cardiovascular disease risk calculators in older populations, the expert clinical consensus emphasizes individualized risk assessment incorporating functional frailty, comorbidity burden, and life expectancy. It concludes that in the absence of life-limiting illness, initiating statin therapy for primary prevention is reasonable in older adults within a structured shared decision-making framework.7
Statins
For most older adults undergoing primary prevention, moderate-intensity statin therapy is appropriate and provides meaningful cardiovascular risk reduction with a favorable safety profile. The dosages shown in Table 2 achieve 30% to 49% LDL-C reduction.1 In accordance with the geriatric prescribing principle “start low, go slow,” treatment should be started at lower dosages with cautious titration based on LDL-C response, tolerability, and patient preference.7
Moderate-intensity statin options for primary prevention of atherosclerotic cardiovascular disease in older adults
Shared decision-making is imperative when initiating statin therapy, with discussion of anticipated benefit, potential harms, and patient preferences. The impact of cardiovascular events on functional status and independence needs to be addressed. Recommended ongoing follow-up prioritizes tolerability and monitoring for muscle symptoms, fatigue, and drug interactions. Decisions regarding dose adjustment or discontinuation need to be individualized, as statin discontinuation in some older adults has been associated with increased cardiovascular risk6 (Table 1).
Meta-analyses and large patient registries have not shown an increased incidence of statin-associated symptoms in adults over age 75, supporting their cautious use in appropriately selected patients.3,5,8
Nonstatin therapies
Nonstatin lipid-lowering therapies are appropriate alternatives when statin intolerance or patient preference limits statin use. In EWTOPIA 75 (Ezetimibe Lipid-Lowering Trial on Prevention of Atherosclerotic Cardiovascular Disease in 75 or Older),9 ezetimibe monotherapy reduced major atherosclerotic cardiovascular events by 34% in adults older than 75 without atherosclerotic cardiovascular disease.
Subgroup analysis of data from CLEAR Outcomes (Evaluation of Major Cardiovascular Events in Participants With, or at High Risk for, Cardiovascular Disease Who Are Statin Intolerant Treated With Bempedoic Acid [ETC-1002] or Placebo)10 showed that bempedoic acid reduced major cardiovascular events by about 30% in patients at high risk of a cardiovascular event (primary prevention) who were unable or unwilling to take statins.
There is limited evidence that these therapies improve overall survival in primary prevention populations, particularly in older adults.
Caveat: Chronological vs biological age
Long-term cardiovascular benefits of statins are unlikely to be realized in older adults with cognitive and functional impairment, frailty, and competing health risks (Figure 1). Current evidence and guidelines generally advise against starting statin therapy in those with limited life expectancy, prioritizing reduced treatment burden and quality of life.7
Primary prevention of hyperlipidemia in adults over age 65 with elevated low-density lipoprotein cholesterol (LDL-C).
A patient whose cognitive impairment is primarily vascular in origin and associated with established cerebrovascular disease may be a candidate for secondary prevention. Advanced dementia, frailty, and limited life expectancy may still support a decision not to start therapy.
LOOKING AHEAD: EVIDENCE GAPS AND ONGOING TRIALS
Ongoing trials such as STAREE (Clinical Trial of Statin Therapy for Reducing Events in the Elderly)11 are expected to clarify the role of statins in primary prevention in adults age 70 and older by focusing on disability-free survival, functional independence, cognition, frailty, and quality of life, in addition to cardiovascular events. These trials will help refine treatment decisions in older adults, a population underrepresented in previous trials. Adults over age 75 have been substantially underrepresented in primary prevention trials.3
When there is uncertainty about statin initiation in patients with reasonable life expectancy and statin time to benefit, coronary artery calcium scoring is a useful tool. The 2025 National Lipid Association and American Geriatrics Society consensus7 supports coronary artery calcium–guided decisions in adults age 76 to 80, recommending statins when the calcium score is at least 100 and deferral when the score is 0. This strategy may shape future guidelines by promoting wider adoption of coronary artery calcium–based risk stratification for primary prevention in older adults.
Despite its growing clinical importance, evidence guiding statin discontinuation in older adults remains inadequate, with limited randomized data to inform discontinuation decisions. Ongoing trials, notably STREAM (Statins in Multimorbid Older Adults Without Cardiovascular Disease)12 and PREVENTABLE (Pragmatic Evaluation of Events and Benefits of Lipid Lowering in Older Adults),13 are expected to provide complementary insights into statin discontinuation in older adults and further refine individualized clinical decision-making.
THE BOTTOM LINE
The decision to start a statin for primary prevention in an older adult should reflect biological age and functional status rather than chronological age alone. Function, prognosis, and goals of care matter more than LDL-C targets alone.
DISCLOSURES
Dr. Hashmi has disclosed being an advisor or review panel participant for Cognivue Inc. The other authors report no relevant financial relationships which, in the context of their contributions, could be perceived as a potential conflict of interest.
- Copyright © 2026 The Cleveland Clinic Foundation. All Rights Reserved.
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