WINSTON-SALEM, N.C. -- In an era when many physicians believe that elderly patients are overmedicated, a new study in Winston-Salem and elsewhere finds that many elderly patients with high cholesterol levels are undertreated -- even those who had a history of coronary heart disease.
Investigators monitoring participants in the Cardiovascular Health Study (CHS) found that less than 20 percent of those eligible for drugs according to 1993 guidelines of the National Cholesterol Education Panel actually got them, said Curt Furberg, M.D., Ph.D., professor and chairman of the Department of Public Health Sciences at the Wake Forest University School of Medicine.
Furberg said he was concerned about the findings. He is national principal investigator of CHS, the largest study ever of the natural progression of heart disease and stroke in the elderly, and co-author of a report that appeared recently in the Archives of Internal Medicine.
Heart disease remains the leading cause of death for people over 65. Recent evidence suggests that elevated cholesterol levels remain a risk factor for death from coronary heart disease in the elderly in otherwise good health.
"Given the clinical trial evidence for benefit, those aged 65 to 75 years and with prior coronary heart disease appeared undertreated with cholesterol lowering drug therapy," the report concluded.
At the 1989 start of the Cardiovascular Health Study, sponsored by the National Heart, Lung and Blood Institute, 4.5 percent of the men and 5.9 percent of the women were using cholesterol-lowering drugs. By 1996, 8.1 percent of men and 10 percent of women were using the drugs. Though the study is ongoing, later figures are not available.
The Cardiovascular Health Study originally enrolled 5,201 men and women over the age of 65 in Forsyth County (Winston-Salem), N.C., Washington County (Hagerstown), Md., Allegheny County (Pittsburgh) Pa., and Sacramento County, Calif. All those who have survived are now at least 72, and some are in their 90s or older. The study is designed to mirror the elderly population as a whole. In 1992-93, 687 African-Americans over 65 were added to the study.
CHS is an observational study. The health of the participants is monitored regularly, and physical condition, lifestyle, diet and other parameters are recorded, but diagnosis and treatment is left in the hands of personal physicians. The investigators said they did not know why the participants were undertreated with drugs. "Older patients and their physicians may have preferred dietary therapy over pharmacological treatment and dietary therapy might explain a small proportion of untreated participants eligible for therapy," they said. Furthermore they said they did not have information about the decisions of the personal physicians. "We do not know if study participants did not fill prescriptions for cholesterol-lowering drugs that had been written by their physicians and to what extent the lack of treatment reflected patients' choice."
CHS uses noninvasive, objective measures of both subclinical and clinical chronic diseases -- such as echocardiograms, electrocardiograms, carotid ultrasound (to measure atherosclerosis or hardening of the arteries and its effect on blood supply to the brain), spirometry to measure lung function, fasting glucose levels to look for diabetes, and objective measures of loss of memory and brain function.
The goal of the study is to learn as much as possible about the lifestyles and the physical condition of the participants at the outset, see how these factors affect the development of heart attacks and strokes (which are recorded as they occur), and to monitor changes in lifestyle and physical condition.
Earlier this year, the CHS investigators reported in the Journal of the American Medical Association that even in the elderly, changes in behavior patterns can lead to a longer life. That report showed exercise is linked even in the oldest old -- those over 85 -- with a reduced risk of mortality.
The results demonstrated a stepwise progression, with CHS participants using at least 1,800 calories a week during moderate or vigorous exercise having a five-year death rate of 15.5 per thousand, with death rates rising as level of activity fell. The most sedentary, doing less than 57.5 calories of activity per week, had a death rate of 52.1 per thousand -- more than three times.