Who is at Risk for Atherosclerotic Cardiovascular Disease

Meron Mezgebe, Mercer University College of Pharmacy

Elevated cholesterol increases the risk for developing atherosclerotic cardiovascular disease (ASCVD). [1] For the monitoring of cholesterol levels the American College of Cardiology and American Heart Association (ACC/AHA) recommend an initial lipid panel of patients 21 years or older, with no clinical ASCVD, and not currently on cholesterol-lowering drugs. The ACC/AHA statin benefit group assignment is made using patients’ age, comorbidities, 10-year ASCVD risk, and lipid panel. [2] A systematic review on lipid screening of younger adults (21-39 years) found no studies directly evaluating the effects of lipid screening versus no screening in younger adults. [3] The U.S. preventative services task force (USPSTF) recommends screening for lipid disorders in men 35 years or older and women 45 years or older, unless they have increased risk of coronary heart disease. [4]

Prevalence of Elevated Cardiovascular Risk in Young Adults [5]
Design Cross-sectional analysis; N= 9,608
Objective To describe the prevalence of elevated atherosclerotic cardiovascular disease (ASCVD) risk among non-diabetic adults younger than 50 years
Study Groups N/A
Methods Adults aged 30-49 years who participated in the examination component of the National Health and Nutrition Examination Survey (NHANES) were considered for inclusion. Participants were excluded if they were receiving a statin or other lipid-lowering drug at the time of the visit, had missing data or self-reported having diabetes, stroke, coronary artery disease, or cardiovascular disease (congestive heart failure, myocardial infarction, or angina).

The NHANES survey provides nationally representative estimates using a complex, multistage, clustered probability method to sample noninstitutionalized U.S. civilians.

NHANES data from 1999 to 2000 through 2011 to 2012 were analyzed.

Duration 1999 – 2012
Primary Outcome Measure Prevalence of elevated ASCVD risk in U.S. adults
Baseline Characteristics
Characteristic Value
Mean age, years (SD) 39.4 (4.7)
Male, % (95% CI) 48.9 (47.8 – 50.1)
Race, % (95% CI)  
White 68.3 (65.9 – 70.8)
African American 10.7 (9.5 – 12.0)
Hispanic 15.1 (13.6 – 16.7)
Hypertension, % (95% CI) 18.6 (17.4 – 19.8)
Mean blood pressure, mmHg (SD)  
Systolic 117.00 (11.3)
Diastolic 73.11 (8.7)
Current Smokers, % (SD) 26.6 (25.3 – 28.0)
Mean total cholesterol level, mg/dL (SD) 201.0 (32.4)
Mean HDL-C level, mg/dL (SD) 52.5 (13.2)
Mean LDL-C level, mg/dl (SD) 120.4 (27.4)
Mean 10 year ASCVD risk, % (SD) 1.9 (2.2)
Low-density lipoprotein cholesterol level, % (SD)  
160-189 mg/dL 69.5 (8.4 – 10.6)
> 190 mg/dL 2.9 (2.3-3.5)
Results
Prevalence of Elevated ASCVD Risk in U.S. Men aged 30 – 49 years
Age group, years Smokers,

% (95% CI)

Nonsmokers with Hypertension,

% (95% CI)

Nonsmokers without Hypertension,

% (95% CI)

30-34 8.4 (5.5–12.5) 2.0 (0.3–13.2) 0 (0–0.5)
35-39 25.6 (21.1–30.7) 2.5 (1.4–4.7) 0.2 (0–0.7)
40-44 53.1 (47.2–58.9) 6.9 (4.4–10.6) 1.2 (0.5–3.2)
45-49 75.9 (69.1–81.6) 29.3 (22.6–37.1) 4.6 (2.7–7.6)
Prevalence of Elevated ASCVD Risk in U.S. Women aged 30 – 49 years
Age group, years Smokers,

% (95% CI)

Nonsmokers with Hypertension,

% (95% CI)

Nonsmokers without Hypertension,

% (95% CI)

30-34 19.5 (14.0–26.5) 0 (0–4.0) 0 (0–0.4)
35-39 13.9 (10.4–18.5) 0.7 (0.2–2.8) 0.1 (0–1.0)
40-44 13.3 (8.9–19.4) 1.9 (0.9–4.1) 0 (0–0.5)
45-49 18.5 (13.5–25.0) 3.7 (1.7–7.8) 0 (0–0.6)
Adverse Events N/A
Study Author Conclusions In the absence of risk factors (smoking, hypertension), the prevalence of increased ASCVD risk is low among women younger than 50 and men younger than 40 years.

Although the NHANES data is a nationally representative of healthy young adults, it was self-reported by the participants, potentially resulting in reporter bias, a limitation of the study. Additionally, the results from this study is not representative of the entire population as, patients receiving a statin or lipid-lowering drug at the initial visit were excluded. Finally, predicted risk was measured, not actual cardiovascular outcomes. The findings of this study support the USPSTF over the ACC/AHA screening recommendations. Young adults without hypertension and are non-smokers were found to have low ASCVD risk and might not benefit from cholesterol screenings until older age.

References

[1] Roy S. Atherosclerotic Cardiovascular Disease Risk and Evidence-basedManagement of Cholesterol. N Am J Med Sci. 2014 May;6(5):191-8.

[2] Stone NJ, Robinson JG, Lichtenstein AH, et al; American College of Cardiology/American Heart Association Task Force of Practice Guidelines. 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 Jul 1;63(25 Pt B):2889-934.

[3] Chou R, Dana T, Blazina I, et al. Screening for Dyslipidemia in Younger Adults: A Systematic Review for the U.S. Preventive Services Task Force. Ann Intern Med. 2016 Oct 18;165(8):560-564.

[4] U.S. Preventive Services Task Force. Lipid disorders in adults (cholersterol, dyslipidemia): screening. June 2008.

[5] Patel KK, Taksler GB, Hu B, Rothberg MB. Prevalence of Elevated Cardiovascular Risks in Young Adults: A Cross-sectional Analysis of National Health and Nutrition Examination Surveys. Ann Intern Med. 2017 Jun 20;166(12):876-882.

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