Elderly (men ≥ 65 years; women ≥ 75 years)

Most new CHD events and most coronary deaths occur in older persons. This is because older persons have accumulated more coronary atherosclerosis than younger age groups. Clinical trial data indicate that older persons with established CHD show benefit from LDL-lowering therapy. Therefore, benefits of intensive LDL lowering should not be denied to persons with CHD solely on the basis of their age.

To reduce the prevalence of CHD in older persons, risk factors should be controlled throughout life. Nonetheless, a high level of LDL cholesterol and low HDL cholesterol still carry predictive power for the development of CHD in older persons. ATP III reaffirms the position taken in ATP II that older persons who are at higher risk and in otherwise good health are candidates for cholesterol-lowering therapy. The difficulty in selection of older persons for LDL-lowering drugs lies in the uncertainties of risk assessment. Risk factors, particularly LDL cholesterol, decline in predictive power. For this reason, risk assess- ment by Framingham scoring may be less reliable in older persons. A partial solution to this problem is the measurement of subclinical atherosclerosis by noninvasive techniques. If an older person is found to have advanced coronary or systemic atherosclerosis, LDLlowering therapy can be intensified even in the absence of clinical coronary symptoms.

Beyond risk assessment, many other factors come into play in older persons that can affect the decision to employ LDL-lowering drugs. These include coexisting diseases, social and economic considerations, and functional age. If Framingham scoring is used to estimate risk in older persons, a more rational decision about initiation of cholesterol-lowering drugs may derive from an examination of the number needed to treat for benefit rather than from a given risk cutpoint.