Statin initiation lowers mortality risk in elderly with moderate chronic kidney disease: JAMA

A target trial emulation of statin initiation in the cohort study of 14,828 participants revealed that statins were significantly associated with a 9% reduced risk of all-cause mortality. There was a numerically lower MACE risk, but the results were not statistically significant.

Atherosclerotic cardiovascular disease is the leading cause of mortality among older adults with chronic kidney disease. Yet, data is limited for the role of statins in primary ASCVD prevention in individuals with moderate CKD (stages 3-4). To fill this knowledge gap, Odeya Barayev, Ben Gurion University of the Negev, Be’er Sheva, Israel, and colleagues aimed to evaluate the association of statin use with MACE and all-cause mortality among US veterans older than 65 years with CKD stages 3 to 4.

A target trial emulation design was used for statin initiation among veterans with moderate CKD using nested trials with a propensity weighting approach. Medicare, Linked Veterans Affairs (VA) Healthcare System, and Medicaid data were used.

The study enrolled veterans newly diagnosed with moderate CKD between 2005 and 2015 in the VA and followed up through December 31, 2017. Veterans were older than 65 years, within 5 years of CKD diagnosis, with no prior statin use or ASCVD, and had at least 1 clinical visit in the year before trial baseline.

The study's primary outcome was all-cause mortality; the secondary outcome was time to first MACE (transient ischemic attack, myocardial infarction, stroke, mortality, or revascularization).

The study led to the following findings:

• The analysis included 14,828 veterans. The mean age at CKD diagnosis was 76.9 years, 99% were men.
• After expanding to person-trials and assessing eligibility at each baseline, there were 151 243 person-trials (14 685 individuals) of nonstatin initiators and 2924 person-trials (2924 individuals) of statin initiators included.
• Propensity score adjustment via overlap weighting with nonparametric bootstrapping resulted in covariate balance, with a mean follow-up of 3.6 years.
• The hazard ratio for all-cause mortality was 0.91, comparing statin initiators to noninitiators.
• The hazard ratio for MACE was 0.96. Results remained consistent in prespecified subgroup analyses.

"Statin initiation among US veterans older than 65 years with CKD stages 3 to 4 and no prior ASCVD was associated with a lower risk of all-cause mortality compared with no statin initiation," the researchers wrote. There is a need to confirm these results in a randomized clinical trial."

"However, until such trials are completed, these data argue against deprescribing or withholding statins for primary prevention in older patients with CKD stages 3 to 4," they concluded.

Reference:

Barayev O, Hawley CE, Wellman H, et al. Statins, Mortality, and Major Adverse Cardiovascular Events Among US Veterans With Chronic Kidney Disease. JAMA Netw Open. 2023;6(12):e2346373. doi:10.1001/jamanetworkopen.2023.46373