Aggressive therapy with statins in elderly and malnourished patients with acute myocardial infarction: is the right time to change?

The changes in the demographic profile of the population with longer life expectancy are mainly due to an improvement of lifestyle, prevention and care of chronic diseases, such as cardiovascular disease.

Currently, the cardiovascular patient is very old and often presents geriatric syndromes, affecting healthcare goals, outcomes and the process of care. “Old age” is a potent independent risk factor for adverse outcomes following myocardial infarction because takes account of comorbidity, poly-drug use, frailty and other complex care that increase management risks and insecurity of outcomes. Moreover, elderly patients often undergo complex invasive procedures and are cured with therapeutic protocols tested on young-adult patients. Management and health care of elderly patients with acute myocardial infarction (AMI) is a field of research that so far has not been sufficiently investigated. Malnutrition is an important aspect of frailty and has several consequences in acute patients, since it involves the organic systemic decline including the immune system.[1]–[3]

Clinically, malnourished patients stay longer in the coronary care unit, have more complications and their malnutrition has a significant impact on their outcomes.[2],[4] Using detailed clinical data from a large study of elderly patients with AMI, recently it has been found that underweight patients were at higher risk of short- and long-term mortality after AMI than normal weight patients.[5] Among the hypotheses suggested by Bucholz, et al.,[5] the higher mortality in underweight patients may be attribute to the fact that patients with low body mass index (BMI) have decreased physiologic reserve and fat stores, which may lower their ability to withstand insults to health over time and make them more vulnerable to adverse events. Coronary artery disease patients have major metabolic needs due to activation of neuro-hormonal and inflammatory pathways. Hence, undernourished patients are at higher risk of infection, complications, and, at last, repeated hospitalizations. The energy reserves may represent a support to the occurrence of such emergency.

Several epidemiological studies suggest that obesity may confer protection and constitute a favorable prognostic factor in some common disease settings. This phenomenon, named “obesity paradox”, has been observed also in acute coronary syndromes patients.[6] While the reasons of this paradoxical phenomenon are currently unknown, we cannot rule out that the differences in survival can be attribute to a better nutritional status of the patients with a higher body mass index.

From few years, some objective indices, such as the controlling nutritional status (CONUT) and the prognostic nutritional index (PNI) have been developed to evaluate the nutritional status.[7],[8] Simple blood biomarkers are required to calculate these two indices. The CONUT index, based on serum albumin, cholesterol and lymphocytes, is an efficient tool for the early detection and continuous control of the under-nutritional status in hospital and has been studied in acute and chronic heart failure.[7] The PNI, calculated by serum albumin level and lymphocyte count, reflects the immunological nutritional condition and measures the risk of a surgical patient to develop a complication.

We recently found that in elderly ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention with stent, the “nutritional status” in addition to other comorbidities, can affect the prognosis of two-year survival follow-up.[8] In our study, the more interesting finding has been the different prognostic value resulted by the two indices. In fact, patients with severe CONUT but not patients with severe PNI index had the highest event rate for all-cause death. Since the two indices differ only for the inclusion of the cholesterol value, to calculate the CONUT index but not the PNI index, we can assume that the more low energy reserve determines a poorer prognosis.

Therefore, we believe that there is possibility to interfere on prognosis of elderly patients by acting on cholesterol levels and more properly on statin treatment. We suggest a personalized nutritional treatment beside an accurate assessment of the appropriateness of lipid-lowering treatment after percutaneous coronary intervention to improve outcomes in these patients. Although the statin treatment remains the gold standard for secondary prevention of coronary artery disease, the beneficial effects of statins in elderly patients should be better clarified because the risk of cardiovascular disease associated to dyslipidemia in older population is complex and is affected by malnutrition and inflammation. A recent study has shown that in a cohort of older adults hospitalized with coronary artery disease, statin therapy had no effect on long-term survival, raising the question about the benefit of statin therapy for secondary prevention in a real-world population of adults aged 80 and older.[9] This study leads us to reflect to take a different treatment strategy for this age group of patients.

It must be emphasized that from the latest recommendations of the ESC/EAS guidelines for the management of dyslipidemias,[10] a shared decision-making has been taken regarding the prescribing statins to lower the cardiovascular risk in older patients. In fact in the new guidelines, the use of lower-intensity statin therapy should be considered in elderly patients at increased risk of adverse effects with high-intensity statins due to comorbidities or potential interaction with essential concomitant therapies.[10]

Nevertheless, the state of malnutrition associated with older age, which can represent an important comorbidity, has not been still taken into account by the new guidelines.[10] In the clinical field, the main problems for physicians of the coronary care unit are the nutritional screening tools to recognize patients with malnutrition and the pathophysiological knowledge of the nutrition for a correct interaction with nutritionists.

We believe that underweight and malnourished patients may benefit of a patient-centered risk management strategy that focus on promoting nutritional status and weight gain. Such strategies may include caloric supplementation in addition to tailored pharmacotherapy. However, trials are needed to test whether use of these new strategies improves survival after AMI in elderly patients.