Cardiovascular effect of discontinuing statins for primary prevention at the age of 75 years: a nationwide population-based cohort study in France

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  Figure 1. Diagram of the study design. Patients with an outcome or censoring event before the start of follow-up at month m = 3 were excluded. ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin II receptor blocker.

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  Figure 2. Patient selection flow chart. aMedication possession ratio, calculated as the sum of the days with exposure to statins over the period considered divided by the total number of days in this period. Statin exposure was determined as indicated in the text. bAt least one of the following therapies: (i) combined use of aspirin and another antiplatelet agent (prescriptions filled on the same day), (ii) combined use of antiplatelet agent, β-blocker, and angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker or aliskiren (prescriptions filled on the same day), (iii) long-term treatment by an antiplatelet agent other than aspirin (at least three prescriptions filled during at least one of the 6 years before the 75th birthday). Time was divided into calendar months. Month m = 0 refers to the month of the 75th birthday.

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  Figure 3. Adjusted cumulative incidence of hospital admission for cardiovascular events according to statin use. Follow-up started at month 3 after the month of the 75th birthday. Cumulative incidence functions were adjusted for confounding due to all baseline and time-varying covariates listed in Table 1 and Supplementary material online, Table S4 (except for the use of other lipid-lowering agents during follow-up), plus the year of the 75th birthday, using inverse probability of treatment and censoring weighting. 95% confidence intervals are indicated by hatched curves. Under the assumptions required by this method (see Supplementary material online, Table S2), the cumulative incidence estimated for statin discontinuation represents the experience of the entire study population had all individuals discontinued statins right from the beginning of follow-up. The cumulative incidence estimated for statin continuation represents the experience of the entire study population had no individuals discontinued statins during follow-up. CI, confidence interval; HR, hazard ratio.

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  Figure 4. Estimated effect of statin discontinuation in patient subgroups. aLow intensity: fluvastatin 20–40 mg, pravastatin 10–20 mg, simvastatin 5–10 mg; moderate intensity: atorvastatin 10–20 mg, rosuvastatin 5–10 mg, fluvastatin 80 mg, pravastatin 40 mg, simvastatin 20–40 mg; high intensity: atorvastatin 40–80 mg, rosuvastatin 20 mg (rosuvastatin 40 mg and simvastatin 80 mg are not available in France). The outcome was hospital admission for cardiovascular event. All patient subgroups were defined at baseline. The estimated effects were adjusted for confounding due to all baseline and time-varying covariates listed in Table 1 and Supplementary material online, Table S4 (except for the use of other lipid-lowering agents during follow-up), plus the year of the 75th birthday. The result for the fluvastatin subgroup was omitted due to the small sample size of this subgroup (a total of 6345 patients with 11 and 277 events on statin discontinuation and continuation, respectively). CI confidence interval; HR, hazard ratio.