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

Younger individuals had a lower 10-year ASCVD risk score (median 6.4%, IQR:3.7–10.4) calculated before their index MI compared with middle-aged (11.6%, IQR: 7.3–17.2) and older (19.6%, IQR: 13.4–28.4) patients (p<0.001). 10-year ASCVD risk score was calculated only among patients >40 years of age. Lifetime risk was higher in younger patients compared to middle-aged and older ones (33.9%, IQR: 29.2-39.6; 32.2%, IQR: 29.4-38.2; and 31.9%, IQR: 29.3-37.2, P<0.001, respectively)
The 2018 guidelines identified less younger adults (<55 years of age) to meet a Class I and IIa recommendation for statin therapy before their first MI compared to the 2013 guidelines (2013: 56.7% and 2018: 46.4%; P<0.01). In contrast, 85.1% (2013) and 88.2% (2018) of the old adults (66-75 years of age) would be eligible for statin therapy when applying the guidelines. Even when including patients with borderline risk (ASCVD 5% to 7.5%) and a risk enhancer, the proportion of statin-eligible young patients (>55 years of age) increased by 6.2%.
According to the 2018 guidelines, 28.3% of the younger patients met very high-risk criteria for intensive secondary prevention lipid-lowering therapy following their MI compared with 40.0% of middle-aged and 81.4% of older patients (P trend <0.001).
During the 8 year follow-up, younger patients with very high-risk criteria were at higher risk of all-cause death, MI, or stroke compared with patients without very high-risk criteria (44.6% vs. 25.9%; HR 2.09, 95% CI: 1.82 to 2.41, P<0.001). These observations were consistent (P=0.53) among middle-aged patients (55 to 65 years of age: 48.1% vs. 28.5%; HR 1.97, 95% CI: 1.72 to 2.27, P<0.001) and old patients (66 to 75 years of age: 53.6% vs. 40.8%; HR 1.51, 95% CI: 1.23 to 1.84, P<0.001).

Conclusion

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.

References

Show references

1. Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/ APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2018;73:e285–350.

2. Collet JP, Zeitouni M, Procopi N, et al. Longterm evolution of premature coronary artery disease. J Am Coll Cardiol 2019;74:1868–78.

3. Navar-Boggan AM, Peterson ED, D’Agostino RB Sr., Pencina MJ, Sniderman AD. Using age- and sex-specific risk thresholds to guide statin therapy: one size may not fit all. J Am Coll Cardiol 2015;65:1633–9.

4. Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;63:2889–934

5. Mach F, Baigent C, Catapano AL, et al. 2019 ESC/EAS guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. The Task Force for the Management of Dyslipidaemias of the European Society of Cardiology (ESC) and European Atherosclerosis Society (EAS). Eur Heart J 2020;41:111–88.

6. Pencina MJ, Navar-Boggan AM, D’Agostino RB Sr., et al. Application of new cholesterol guidelines to a population-based sample. N Engl J Med 2014;370:1422–31.

7. Pagidipati NJ, Navar AM, Mulder H, Sniderman AD, Peterson ED, Pencina MJ. Comparison of recommended eligibility for primary prevention statin therapy based on the US Preventive Services Task Force Recommendations vs the ACC/AHA guidelines. JAMA 2017; 317:1563–7.

8. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA 2001;285: 2486–97.

9. Singh A, Collins BL, Gupta A, et al. Cardiovascular risk and statin eligibility of young adults after an MI: Partners YOUNG-MI Registry. J Am Coll Cardiol 2018;71:292–302.

10. Akosah KO, Schaper A, Cogbill C, Schoenfeld P. Preventing myocardial infarction in the young adult in the first place: how do the National Cholesterol Education Panel III guidelines perform? J Am Coll Cardiol 2003;41: 1475–9.

Find this article online at J Am Coll Cardiol.