Rethinking global statin guidelines for older adults in resource-diverse settings

Statin guidelines for older adults are predominantly informed by evidence from high-income countries (HICs), making them less relevant in low- and middle-income countries (LMICs) with varying healthcare capacities. Identical patients may receive different recommendations depending on the geographic context, as seen in European Systematic Coronary Risk Evaluation 2 (SCORE2) and USA's Predicting Risk of Cardiovascular Disease EVENTs (PREVENT) guidelines. LMICs often rely on the World Health Organization cardiovascular risk charts and implementation frameworks, such as the package of essential non-communicable disease interventions and HEARTS. While these frameworks are generally more feasible in resource-limited settings, they lack the clinical specificity of HIC-based guidelines. Emerging biological evidence challenges uniform cholesterol-lowering therapies in older adults. Polypharmacy, potential adverse effects, and the limited capacity for ongoing monitoring in many settings further complicate the net benefit of statin therapy in this population. These challenges underscore the need for context-sensitive, age-appropriate guidelines. We outline a context-sensitive approach to statin use in older adults and propose guiding principles to support more equitable, feasible, and clinically appropriate decision making. These include aligning treatment with functional status and prognosis, using fixed-dose combinations, and integrating statin use into broader primary care strategies through task-sharing and simplified protocols. To ensure meaningful cardiovascular disease prevention in ageing populations, global guidelines must evolve to reflect regional capacity, biological variation, and implementation.