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Hypercholesterolemia and the ageing subject
European Journal of Internal Medicine 21 (2010) e19
Contents lists available at ScienceDirect
European Journal of Internal Medicine j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / e j i m
Letter to the Editor Hypercholesterolemia and the ageing subject
To the Editor: Iversen et al. have recently dealt in this Journal, with the effects of total cholesterol (TC) levels on cardiovascular risk according to age in a healthy population from the Copenhagen City Heart Study. They conclude that the association between high TC and incident coronary heart disease (CHD) event rate declines progressively with advancing age and is no more valid above 80 years [1]. This thorough survey considers more than 10,000 men and women before statin introduction in Denmark; its conclusions are in agreement with other cohort investigations but rely simply on total cholesterol and not on other useful lipid parameters. On the other hand data from a recent meta-analysis (61 prospective observational studies), consisting of almost 900,000 adults without previous disease, disclose that 1 mmol/L lower TC was associated with a statistically significant hazard ratio of 0.72, 0.82 and 0.85 lower CHD mortality in both sexes at ages 60–69, 70–79 and 80–89 years, respectively, and that HDL-cholesterol (HDL-C) and TC to HDL-C ratio are more informative parameter than total cholesterol alone [2]. We agree with the latter conclusions, pointing out that the EPESE Study related the apparent adverse effects associated with low TC levels in very old patients (average baseline age of 79) to comorbidity and frailty, and that adjusting for potential confounders (among which HDL-C) restored the direct relationship between TC and CHD in this population characterized by a heterogeneous health state [3]. Also the experience matured by our study-group suggests a prominent effect related to HDL-C [4], showing that free-living healthy octo-nonagenarians (free from CHD and stroke) are not characterized by high HDL-C or low LDL-C levels, but by a very low prevalence of low HDL-C (3.9%) [5], while HDL-C levels associate also with functional status [6]. Besides, while we could not exclude that dyslipoproteinemic highcholesterol value in old people is under-represented since abated by premature death in affected individuals, we maintain that also small increases in relative CHD risk in elderly individuals associate with a
striking increase in absolute risk, given the high prevalence of CHD with advancing age. This suggests that excluding older persons from cholesterol screening may be inappropriate, but that a comprehensive lipid profile and clinical judgment is essential for deciding if pharmacological treatment is needed. References [1] Iversen A, Jensen JS, Scharling H, Schnohr P. Hypercholesterolemia and risk of coronary heart disease in the elderly. Impact of age. The Copenhagen City Heart Study. Eur J Int Med 2009;20:139–44. [2] Prospective Study Collaboration. Blood cholesterol and vascular mortality by age, sex, and blood pressure: a meta-analysis of individual data from 61 prospective studies with 55,000 vascular deaths. Lancet 2007;370:1829–39. [3] Corti MC, Guralnik JM, Salive ME, Harris T, Ferrucci L, Glynn RJ, Havlik RJ. Clarifying the direct relation between total cholesterol levels and death from coronary heart disease in older persons. Ann Int Med 1997;126:753–60. [4] Volpato S, Leveille SG, Corti MC, Harris TB, Guralnik JM. The value of serum albumin and high-density lipoprotein cholesterol in defining mortality risk in older persons with low serum cholesterol. J Am Geriatr Soc 2001;49:1142–7. [5] Zuliani G, Palmieri E, Volpato S, Bader G, Mezzetti A, Costantini F, et al. High-density lipoprotein cholesterol strongly discriminates between healthy free-living and disabled octo-nonagenarians: a cross sectional study. Aging 1997;9:335–41. [6] Volpato S, Ble A, Metter EJ, Lauretani F, Bandinelli S, Zuliani G, et al. High-density lipoprotein cholesterol and objective measures of lower extremity performance in older nondisabled persons: the InChianti study. J Am Geriatr Soc 2008;56:621–9.
Giovanni Battista Vigna⁎ Giovanni Zuliani Renato Fellin Department of Clinical and Experimental Medicine, Section of Internal Medicine, Gerontology and Geriatrics, University of Ferrara, Italy ⁎Corresponding author. Department of Clinical and Experimental Medicine, Section of Internal Medicine, Gerontology and Geriatrics, University of Ferrara, via Savonarola, 9, 44100 FERRARA, Italy. Tel.: +39 0532 247409; fax: + 39 0532 210884. E-mail address: [email protected] (G.B. Vigna).
0953-6205/$ – see front matter © 2009 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.ejim.2009.12.009
11 December 2009
Contents lists available at ScienceDirect
European Journal of Internal Medicine j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / e j i m
Letter to the Editor Hypercholesterolemia and the ageing subject
To the Editor: Iversen et al. have recently dealt in this Journal, with the effects of total cholesterol (TC) levels on cardiovascular risk according to age in a healthy population from the Copenhagen City Heart Study. They conclude that the association between high TC and incident coronary heart disease (CHD) event rate declines progressively with advancing age and is no more valid above 80 years [1]. This thorough survey considers more than 10,000 men and women before statin introduction in Denmark; its conclusions are in agreement with other cohort investigations but rely simply on total cholesterol and not on other useful lipid parameters. On the other hand data from a recent meta-analysis (61 prospective observational studies), consisting of almost 900,000 adults without previous disease, disclose that 1 mmol/L lower TC was associated with a statistically significant hazard ratio of 0.72, 0.82 and 0.85 lower CHD mortality in both sexes at ages 60–69, 70–79 and 80–89 years, respectively, and that HDL-cholesterol (HDL-C) and TC to HDL-C ratio are more informative parameter than total cholesterol alone [2]. We agree with the latter conclusions, pointing out that the EPESE Study related the apparent adverse effects associated with low TC levels in very old patients (average baseline age of 79) to comorbidity and frailty, and that adjusting for potential confounders (among which HDL-C) restored the direct relationship between TC and CHD in this population characterized by a heterogeneous health state [3]. Also the experience matured by our study-group suggests a prominent effect related to HDL-C [4], showing that free-living healthy octo-nonagenarians (free from CHD and stroke) are not characterized by high HDL-C or low LDL-C levels, but by a very low prevalence of low HDL-C (3.9%) [5], while HDL-C levels associate also with functional status [6]. Besides, while we could not exclude that dyslipoproteinemic highcholesterol value in old people is under-represented since abated by premature death in affected individuals, we maintain that also small increases in relative CHD risk in elderly individuals associate with a
striking increase in absolute risk, given the high prevalence of CHD with advancing age. This suggests that excluding older persons from cholesterol screening may be inappropriate, but that a comprehensive lipid profile and clinical judgment is essential for deciding if pharmacological treatment is needed. References [1] Iversen A, Jensen JS, Scharling H, Schnohr P. Hypercholesterolemia and risk of coronary heart disease in the elderly. Impact of age. The Copenhagen City Heart Study. Eur J Int Med 2009;20:139–44. [2] Prospective Study Collaboration. Blood cholesterol and vascular mortality by age, sex, and blood pressure: a meta-analysis of individual data from 61 prospective studies with 55,000 vascular deaths. Lancet 2007;370:1829–39. [3] Corti MC, Guralnik JM, Salive ME, Harris T, Ferrucci L, Glynn RJ, Havlik RJ. Clarifying the direct relation between total cholesterol levels and death from coronary heart disease in older persons. Ann Int Med 1997;126:753–60. [4] Volpato S, Leveille SG, Corti MC, Harris TB, Guralnik JM. The value of serum albumin and high-density lipoprotein cholesterol in defining mortality risk in older persons with low serum cholesterol. J Am Geriatr Soc 2001;49:1142–7. [5] Zuliani G, Palmieri E, Volpato S, Bader G, Mezzetti A, Costantini F, et al. High-density lipoprotein cholesterol strongly discriminates between healthy free-living and disabled octo-nonagenarians: a cross sectional study. Aging 1997;9:335–41. [6] Volpato S, Ble A, Metter EJ, Lauretani F, Bandinelli S, Zuliani G, et al. High-density lipoprotein cholesterol and objective measures of lower extremity performance in older nondisabled persons: the InChianti study. J Am Geriatr Soc 2008;56:621–9.
Giovanni Battista Vigna⁎ Giovanni Zuliani Renato Fellin Department of Clinical and Experimental Medicine, Section of Internal Medicine, Gerontology and Geriatrics, University of Ferrara, Italy ⁎Corresponding author. Department of Clinical and Experimental Medicine, Section of Internal Medicine, Gerontology and Geriatrics, University of Ferrara, via Savonarola, 9, 44100 FERRARA, Italy. Tel.: +39 0532 247409; fax: + 39 0532 210884. E-mail address: [email protected] (G.B. Vigna).
0953-6205/$ – see front matter © 2009 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.ejim.2009.12.009
11 December 2009