Diabetes Metab J.  2022 Sep;46(5):722-732. 10.4093/dmj.2021.0225.

Myocardial Infarction, Stroke, and All-Cause Mortality according to Low-Density Lipoprotein Cholesterol Level in the Elderly, a Nationwide Study

Affiliations
  • 1Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
  • 2Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
  • 3Smart Healthcare Center, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
  • 4Department of Biostatistics, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
  • 5Department of Obstetrics and Gynecology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea

Abstract

Background
We assessed the myocardial infarction (MI), stroke, and all-cause death risks during follow-up according to the low-density lipoprotein cholesterol (LDL-C) levels among older adults.
Methods
The Korean National Health Insurance Service datasets (2002 to 2020) were used for this population-based cohort study. The hazards of MI, stroke, and all-cause mortality during follow-up were analyzed according to LDL-C level in individuals aged ≥65 years without baseline cardiovascular diseases (n=1,391,616).
Results
During a mean 7.55 years, 52,753 MIs developed; 84,224 strokes occurred over a mean 7.47 years. After a mean 8.50 years, 233,963 died. A decrease in LDL-C was associated with lower hazards of MI and stroke. The decreased hazard of stroke in lower LDL-C was more pronounced in statin users, and individuals with diabetes or obesity. The hazard of all-cause death during follow-up showed an inverted J-shaped pattern according to the LDL-C levels. However, the paradoxically increased hazard of mortality during follow-up in lower LDL-C was attenuated in statin users and individuals with diabetes, hypertension, or obesity. In statin users, lower LDL-C was associated with a decreased hazard of mortality during follow-up.
Conclusion
Among the elderly, lower LDL-C was associated with decreased risks of MI and stroke. Lower LDL-C achieved by statins in the elderly was associated with a decreased risk of all-cause death during follow-up, suggesting that LDL-C paradox for the premature death risk in the elderly should not be applied to statin users. Intensive statin therapy should not be hesitated for older adults with cardiovascular risk factors including diabetes.

Keyword

Aged; Cardiovascular diseases; Hydroxymethylglutaryl-CoA reductase inhibitors; Lipoproteins; LDL; Mortality

Figure

  • Fig. 1 Kaplan–Meier estimates of cumulative incidence of (A) myocardial infarction, (B) stroke, and (C) all-cause death during follow-up according to the ranges of low-density lipoprotein cholesterol (LDL-C) levels.

  • Fig. 2 Hazard ratios for incident (A) myocardial infarction, (B) stroke, and (C) all-cause death during follow-up according to the low-density lipoprotein cholesterol (LDL-C) levels. Curves represent hazard ratios adjusted for age, sex, body mass index, current smoking, heavy alcohol consumption, regular exercise, low-income status, diabetes, hypertension, and statin use. Solid lines indicate hazard ratios and dashed line indicate 95% confidence intervals using restricted cubic spline regression.

  • Fig. 3 Adjusted hazard ratios and 95% confidence intervals (CIs) for the incidence of (A) myocardial infarction, (B) stroke, and (C) all-cause death during follow-up according to the ranges of low-density lipoprotein cholesterol (LDL-C) levels in subgroups stratified by statin use. Adjusted for age, sex, body mass index, current smoking, heavy alcohol consumption, regular exercise, low-income status, diabetes, hypertension, and statin use.


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