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Abstract：
Introduction: European guidelines recommend the implementation of lipid-lowering therapies (LLTs) in adults (≥ 65 years) with established atherosclerotic cardiovascular disease (ASCVD) and for risk-based primary prevention in older adults (≤ 75 years), yet their use in very-old adults (> 75 years) is controversial, discretionary, and oriented on the presence of risk factors. The aim of this retrospective study is to assess guideline-directed LLT implementation and low-density lipoprotein cholesterol (LDL-C) target achievement in high-/very-high-risk older/very-old adults (65-74 and ≥ 75 years) at presentation for ST-segment elevation myocardial infarction (STEMI) and also to assess evidence-based care delivery to older adults in our region. Methods: All STEMI patients with available LDL-C and total cholesterol presenting for treatment at a large tertiary center in Salzburg, Austria, 2018-2020, were screened (n = 910). High-risk/very-high-risk patients (n = 369) were classified according to European guidelines criteria and divided into cohorts by age: < 65 years (n = 152), 65-74 years (n = 104), and ≥ 75 years (n = 113). Results: Despite being at high-/very-high-risk, prior LLT use was < 40% in the total cohort, with no significant difference by age. Statin monotherapy predominated; 20%-23% of older/very-old adults in the entire cohort were using low-/moderate-intensity stains, 11%-13% were using high-intensity statins, 4% were on ezetimibe therapy, and none were taking proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors. In the secondary prevention cohort, 53% of older/very-old patients used prior LLTs. Significantly higher percentages of older/oldest ASCVD patients (43% and 49%) met LDL-C targets < 70 mg/dL compared to patients < 65 years (29%; p = 0.033), although just 22% and 30% of these older groups attained stricter LDL-C targets of < 55 mg/dL. Low LLT uptake (16%) among older adults aged 64-74 years for primary prevention resulted in 17% and 10% attainment of risk-based LDL-C targets < 70 mg/dL and < 55 mg/dL, respectively. Oldest adults (≥ 75 years) in both primary and secondary prevention groups more often met risk-based targets than older and younger adults, despite predominantly receiving low-/moderate-intensity statin monotherapy. Conclusion: Secondary prevention was sub-optimal in our region. Less than half of older/very-old adults with established ASCVD met LDL-C targets at the time of STEMI, suggesting severe care-delivery deficits in LLT implementation. Shortcomings in initiation of risk-based LLTs were also observed among high-/very-high-risk primary prevention patients < 75 years, with the achievement of risk-based LDL-C targets in 10%-48% of these patients.
摘要：
简介：欧洲指南建议在患有动脉粥样硬化性心血管疾病（ASCVD）的成年人（≥65岁）中实施降脂治疗（LLTs），并在老年人（≤75岁）中实施基于风险的一级预防。然而，它们在高龄成年人(>75岁)中的使用是有争议的，自由裁量,并以风险因素的存在为导向。这项回顾性研究的目的是评估高/极高风险老年人/极高龄成年人（65-74岁和≥75岁）在ST段抬高型心肌梗死（STEMI）中指南指导的LLT实施和低密度脂蛋白胆固醇（LDL-C）目标实现情况，并评估本地区老年人的循证护理服务。方法：所有STEMI患者在萨尔茨堡的大型三级中心接受治疗的LDL-C和总胆固醇，奥地利,2018-2020年，进行了筛选（n=910）。高风险/极高风险患者（n=369）根据欧洲指南标准进行分类，并按年龄分为队列：<65岁（n=152）。65-74岁（n=104），≥75岁(n=113)。结果：尽管处于高风险/非常高风险，以前LLT的使用在总队列中<40%，年龄没有显著差异。他汀单药治疗占主导地位；在整个队列中，20％-23％的老年/非常老年的成年人使用低/中等强度的染色，11%-13%使用高强度他汀类药物，4%的患者接受依泽替米贝治疗，没有人服用前蛋白转化酶枯草杆菌蛋白酶/kexin9型（PCSK9）抑制剂。在二级预防队列中，53％的老年/非常老年患者使用了先前的LLT。与<65岁的患者（29％；p=0.033）相比，年龄较大/年龄较大的ASCVD患者（43％和49％）达到LDL-C指标<70mg/dL的百分比明显更高，尽管只有22％和30％的老年组达到了更严格的LDL-C目标<55mg/dL。在64-74岁的老年人中，低LLT摄取（16％）的一级预防导致17％和10％的基于风险的LDL-C目标<70mg/dL和<55mg/dL，分别。初级和二级预防组中年龄最大的成年人（≥75岁）比老年人和年轻人更容易达到基于风险的目标。尽管主要接受低/中等强度他汀类药物单药治疗.结论：二级预防在我们地区次优。在STEMI发生时，不到一半的患有ASCVD的老年/非常老年的成年人达到LDL-C目标。提示LLT实施中严重的护理交付缺陷。在<75岁的高危/非常高危一级预防患者中，也观察到了基于风险的LLT启动的不足。这些患者中有10％-48％实现了基于风险的LDL-C目标。
