Statins in cardiovascular prevention in the oldest-old. A black hole

Elderly population is increasing rapidly together with the incidence of cardiovascular diseases (CVDs) and cardiovascular (CV) mortality. The evaluation of total CV risk is necessary for prevention of CV events, but the most used assessment tools do not include the elderly population. Among CV risk factors, hypercholesterol-emia increases with the age, but the results about the association between total cholesterol (TC) levels and mortality in the elderly population are controversial. Statins are the first-choice drug for lipid-lowering therapy in the elderly due to their efficacy and safety. In primary prevention there are no recommendations to the use of statins in older adults because they do not reduce the risk of CV and all-cause mortality. On the contrary, statin treatment is recommend both in older than in younger people in secondary prevention because of the reduction of CV and all-causes mortality. High-intensity statins are more effective in the elderly population, but these dosages are associated to an increased incidence of adverse reactions, especially liver dysfunction. Finally, the degree of clinical frailty is inversely related to total cholesterol in the elderly and, accordingly, lower cholesterol levels are associated to higher mortality in this population. There are no studies that specifically evaluated the benefit of lipid-lowering therapy in severely frail older adults and a narrative-based approach, instead of an evidence-based one, has been used to choose the better treatment plan.