In a recent opinion piece for STAT, a young physician described his decision to begin taking a cholesterol-lowering statin, and he warned both young people and their physicians about the lifetime risk of heart attack in these younger age groups.

SUHAS GONDI; sgondi@bwh.harvard.edu 
    Gondi is a resident physician in internal medicine at Brigham and Women’s Hospital. 

“Over half of young adults in the [U.S.],” Gondi wrote, “have cholesterol levels high enough to increase their lifetime risk of a heart attack.” But just 20 percent of young adults with high cholesterol are aware of their cholesterol levels, and Gondi argues that too few young people are getting properly screened for their risk of heart attack.  

Gondi told the Institute for Public Accuracy: “Historically, young adults’ [cardiovascular risk has] been neglected for a number of reasons. First, it’s harder to produce high-quality research in this population.” (Young adults are often excluded from studies because cardiac events are less common in people under the age of 40.) 

Gondi added: “That said, in high-risk groups––including South Asians like me––the community is coming around to the idea that we need to check [risk] earlier. To a lesser extent, but still gaining currency, is the idea that we should be using medication to reduce cardiovascular risk in young adults.

“With better epidemiological studies, we’re learning that in a lot of high-risk groups, heart attacks are happening younger. If you follow current guidelines and wait until [age] 35 to check and [age] 40 to take statins, you miss a lot of opportunities to delay or prevent substantial or devastating events. The current guidelines aren’t serving a large group of the patients we serve.” 

In the past, physicians have primarily recommended “lifestyle modifications” to reduce risk of heart attack. “We should absolutely encourage that,” Gondi said. But “a lot of cholesterol isn’t related to diet or exercise; it’s just about genetics.” The recommendation, he said, “also ignores the reality that a healthy diet and access to a gym are not equally accessible to everyone.”

The evidence makes it clear that there’s a benefit to lowering LDL levels when patients are young––“and keeping it low for as long as possible: lower for longer is better.” High LDL at younger ages poses a greater risk over a lifetime because when coronary arteries are exposed to high levels of lipids year after year, it can lead to the buildup of plaque and inflammation, predisposing a person to a heart attack. 

Because of the cumulative effects of high LDL, Gondi recommends using a metric similar to the pack-year metric used for cigarette smokers, which considers how long a person has been smoking alongside their intake. “That’s the way we should think about cholesterol as well––in cholesterol years.” 

Gondi also noted that although his opinion piece mainly encouraged the use of standard lipid profiles to ascertain cardiovascular risk, physicians can also do imaging or test for other markers that are not traditionally part of the profile. “There are other ways to measure risk. There are also incredible cholesterol-lowering therapies on the horizon, and it would be amazing to see how those might be helpful for risk reduction in young adults.”