Only one in 8 people who suffer a heart attack at age 50 or younger are on preventative statin therapy prior to their event, a new study reported. And what is even more concerning, according to researchers, is most of the untreated individuals weren’t eligible for statins based on guidelines.
“These findings highlight the need for better risk assessment tools among young adults,” concluded senior author Ron Blankstein, MD, and colleagues in the Journal of the American College of Cardiology. They also presented their results Nov. 14 at the American Heart Association’s scientific sessions in Anaheim, California.
The retrospective cohort study included 1,685 patients aged 50 or younger who experienced MI between 2000 and 2016 at Brigham and Women’s Hospital or Massachusetts General Hospital, both in Boston. Only 12.5 percent of those individuals were on statin therapy prior to MI and were excluded from the rest of the analysis, which focused on whether the untreated patients would have been eligible for statins based on 2013 American College of Cariology/American Heart Association (ACC/AHA) guidelines or 2016 United States Preventative Services Task Force (USPSTF) recommendations.
Among the remaining individuals, less than half (49 percent) would have been candidates for statin therapy under the ACC/AHA guidelines versus 29 percent using the 2016 USPSTF recommendations. Using either guideline, 63 percent of women and 46 percent of men in the registry wouldn’t have been eligible for treatment.
The researchers reported the women had a lower presence of hyperlipidemia, lower total cholesterol, LDL cholesterol and triglycerides, but higher HDL cholesterol. They also had a higher prevalence of obesity and 57 percent of them smoked compared to 51 percent of men.
For the entire untreated cohort, more than half presented with ST Elevation MI, 20 percent were women and 72 percent were white. Eighty-three percent of them had at least one cardiovascular risk factor—diabetes, dyslipidemia, hypertension or smoking—and their median 10-year risk of developing atherosclerotic cardiovascular disease (ASCVD) was calculated at 4.8 percent.
“Providers need to be cautious when applying statin recommendations endorsed by guidelines to young individuals under the age of 50, as a low ASCVD risk score maybe falsely reassuring in certain clinical scenarios, and consequently lead to under-treatment,” Blankstein and colleagues wrote. “We recommend that in addition to calculating the ASCVD risk score, clinicians consider incorporating additional risk markers—such as premature family history of CAD (coronary artery disease), or clustering of traditional and novel risk factors—when having risk-benefit discussions with young adults in the context of shared decision making.”
The authors noted younger patients may have more to gain from preventative therapy. A longer exposure to low LDL cholesterol could provide long-term benefits, and people who suffer MI at a younger age might see a greater reduction in lifetime earnings and societal contributions.
Blankstein et al. suggested lowering the ASCVD risk score threshold for statin indication as one potential way to treat more patients. But a more effective method for this cohort was including all patients with LDL cholesterol above 160 milligrams per deciliter and a family history of premature CAD. Applying this measure increased the proportion of patients eligible for treatment from 49 to 66 percent.
“However, any criteria that would identify more at-risk individuals, would lead to a higher proportion of treated patients across the population who would not necessarily experience events,” the researchers wrote. “Thus, while our findings suggest that incorporating the above risk factors in making decisions regarding the role of statins in young individuals may be important, future investigations should further elucidate the population-level impact of such approaches aimed at expanding the number of individuals treated.”