Physicians' Academy for Cardiovascular Education

Half of young adults with premature MI not identified by 2018 cholesterol guidelines

Performance of Guideline Recommendations for Prevention of Myocardial Infarction in Young Adults

Literature - Zeitouni M, Nanna MG, Sun JL et al. - J Am Coll Cardiol. 2020 76(6):653-664. doi: 10.1016/j.jacc.2020.06.030

Introduction and methods

The 2018 American Heart Association (AHA) and American College of Cardiology (ACC) Multisociety Guideline on the Management of Blood Cholesterol provided updates for the risk assessment of patients eligible for statin prescription for primary prevention [1]. Risk enhancers were included in the new criteria [2]. The 2018 guideline also updated secondary prevention therapy, such as non-statin lipid lowering therapies as part of the treatment of patients with myocardial infarction (MI) and at the highest risk for recurrent ASCVD events [3].

The previous 2013 guideline for cholesterol management expanded statin therapy eligibility based upon a 10-year atherosclerotic cardiovascular disease (ASCVD) risk score [4-8]. However, this risk score calculator is heavily dependent upon age and is therefore often underestimating the risk for premature coronary artery disease (CAD) in young patients [3,9,10]. Young adults who develop CAD have high risk of poor outcomes by developing recurrent non-fatal and fatal CVD, emphasizing that early and adequate prevention are thus of paramount importance [2].

This study evaluated how the 2013 guidelines and updated 2018 guidelines on blood cholesterol management changes affected identification of young adults for preventative statin therapy who developed premature ischemic heart disease. The Duke Databank for Cardiovascular Disease (DDCD), a registry of patients who underwent cardiac catherization at Duke University Medical Center, Durham, NC, USA) was used and this study included patients (n=6,639) admitted from 1995 to 2012 for a first acute MI in combination with obstructive CAD (defined as a ≥50% diameter stenosis of the coronary artery). Individuals with previously documented stroke, MI, peripheral artery disease, or obstructive CAD were excluded. Also patients missing blood cholesterol values at the time of or within approximately 1 year of the index catheterization were excluded. The cohort was subsequently divided into the following age groups: <55 years of age (young, n=2,733), 55 to 65 years of age (middle-aged, n=2,324), and 66 to 75 years of age (old, n=1,582).

Main results


The current study provides important evidence that nearly half of young adults who experienced a MI were not eligible for primary prevention statin therapy using the updated 2018 cholesterol guidelines. And far fewer younger individuals would be eligible for the most intensive secondary prevention therapy post MI compared with older adults. A key factor accounting for this is that current risk scores are heavily based on age. Younger patients with very high-risk criteria are at increased risk of MACE and therefore subscription of lipid-lowering therapy in these patients is highly recommended.


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Find this article online at J Am Coll Cardiol.

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