Low-density lipoprotein cholesterol, coronary plaque burden, and cardiovascular risk in individuals beyond 75 years of age

Background The role of low-density lipoprotein cholesterol (LDL-C) in atherosclerotic cardiovascular disease in older individuals remains controversial. Purpose To assess whether LDL-C is associated with plaque burden on coronary computed tomography angiography (CCTA) and future myocardial infarctions (MI) in statin-naïve symptomatic individuals across different ages with a primary focus on individuals aged >75 years. Methods This observational multicenter cohort study included individuals who underwent CCTA between 2008 and 2021, sourced from a Danish national registry. Outcomes and measures included 1) adjusted risk ratio (aRR) for any plaque and early revascularization (within 90 days of CCTA) and 2) adjusted hazard ratio (aHR) for MI. Results The study included 37,910 statin-naïve symptomatic individuals, including 1,562 aged >75 years. During a median follow-up of 5.1 years, 433 individuals experienced MI, including 36 (2%) of those aged >75 years. The prevalence of any plaque was 19,962 (53%) and was associated with LDL-C levels across all age-groups. Thus, the aRR for presence of any plaque and early revascularization was 1.14 (95% CI 1.07-1.22) and 3.18 (1.94-5.23), respectively, in individuals aged >75 years with high versus low LDL-C (>4.4 versus <2.7 mmol/L) being comparable to the association in younger age-groups. The 90-day cumulative incidence proportion (CIP) for early revascularization was 20% (95% CI 13-29%) in individuals aged >75 years with LDL-C >4.4 mmol/L. The aHR for MI was 1.57 (95% CI 1.06-2.32) per 1 mmol/L higher LDL-C for individuals aged >75 years. Conclusion LDL-C was strongly associated with the presence of coronary plaque and elevated cardiovascular risk in individuals beyond 75 years of age. These findings suggest that LDL-C influences prognosis throughout life, leading to a potentially lifelong need for LDL-C management to prevent cardiovascular disease.