Focus More Heart Care on the Young, Study Says

Treatment for high cholesterol typically starts years after damage to arteries has already been done, the new research indicates.

Living decades with high cholesterol greatly increases the risk for heart disease, according to a recent study that bolsters a push by some doctors for regular cholesterol testing and perhaps early drug treatment of people in their 30s and 40s.

About 37% of young adults have never had their cholesterol checked, according to the Centers for Disease Control and Prevention. And when elevated cholesterol levels are found, doctors typically won’t prescribe a drug until patients are in their 50s or 60s. By then, significant damage from years of cholesterol buildup has been done, the new research indicates.

“If we wait until people are in their 50s and 60s to be thinking about high cholesterol, it is probably too late,” said Ann Marie Navar-Boggan, a cardiology fellow at Duke Clinical Research Institute in Durham, N.C., and lead author of the study, which was published in the journal Circulation in January. The risk of developing heart disease increases by 39% for every 10 years a person lives with high cholesterol, the research found.

Heart disease can be prevented through healthier eating, more exercise and weight loss, though many patients find it difficult to make the necessary lifestyle changes. Although statins have been proved to lower cholesterol and reduce the risk of heart attack, the safety and effectiveness of taking the drugs for several decades hasn’t been closely studied. In short-term studies, some people experience side effects to statins including muscle pains.

How far to go in tackling high cholesterol at an early age has been hotly debated among doctors. The latest guidelines from the American Heart Association and American College of Cardiology encourage doctors to counsel those patients to change their lifestyle, but not to take a cholesterol-lowering statin drug unless they have other risk factors, such as a family history of a heart attack at a relatively young age, said Neil Stone, a professor of cardiology at Northwestern University’s Feinberg School of Medicine and lead author of the guidelines.

“Would you really want to give them a statin when lifestyle could take care of the problem?” said Dr. Stone. “We believe in careful, thoughtful use of statins.”

The AHA said it expects the guidelines will be updated within 18 months following a number of scientific developments since the recommendations were last revised in 2013.

Doctors have concentrated their heart-disease-prevention efforts on older patients. The U.S. Preventive Services Task Force recommends routinely checking cholesterol in men 35 years and older, and in women who are over 45, unless they have additional risk factors.

About 43% of people ages 60 to 74 take medicine to lower cholesterol, while just 2% in their 30s and 9% in their 40s do so, according to Seth Martin, a Johns Hopkins Hospital cardiology researcher who made the estimates from analyzing federal health data. Dr. Martin cited the Circulation study as supporting intervening to prevent heart disease decades before heart attacks and strokes typically strike. “Older groups are where most of the [heart attacks and strokes] events are, but that doesn’t mean treating someone earlier in life wouldn’t have been beneficial 30 years down the line,” he said.

Michelle Tucker, a 38-year-old administrative coordinator at Johns Hopkins Hospital in Baltimore, first discovered she had high cholesterol during a routine test in September before cyst-removal surgery. At Dr. Martin’s urging, Ms. Tucker said she began eating salads rather than ham sandwiches for lunch, and she bicycles and walks her dog after work rather than letting the pet run around her backyard. Ms. Tucker also took a statin drug for 60 days to see if it helped control her cholesterol. She plans soon to discuss with Dr. Martin whether to start taking the drug regularly.

“I wish when I was 28 somebody would have said to me” to start changing her lifestyle, before her cholesterol got to unhealthy levels, she said.

The Circulation study aimed to understand the long-term impact of prolonged exposure to high cholesterol. Researchers reviewed health data from 1,478 adults who were part of the landmark Framingham Heart Study, which followed people in Framingham, Mass., for decades. Those people who had high cholesterol (defined as an LDL reading of 130 or higher) for between 11 and 20 years before they turned 55 years old were four times as likely to develop heart disease later in life as people who didn’t have elevated cholesterol levels, the study found. Other factors including obesity and diabetes could have contributed to some of the increased risk, the researchers said.

The findings suggest people in their 30s and 40s with high cholesterol should discuss with their doctors making lifestyle changes and the pluses and minuses of taking a statin drug, Dr. Navar-Boggan said.

The AHA/ACC guidelines tend to recommend against prescribing statins to people in their 30s and 40s unless they have major risk factors. The guidelines focus on a patient’s risk of heart disease, rather than cholesterol levels. The risk is based on a formula that heavily weights a patient’s age, meaning younger people don’t usually receive a score high enough for a doctor to recommend drug treatment, according to the Circulation study.

Robert H. Eckel, a past president of the American Heart Association who helped write the guidelines, said doctors and patients can use the study’s findings to complement the recommendations. He said the guidelines direct doctors to conduct further testing on younger patients who appear to be at higher long-term risk of developing heart disease to see if stronger action than lifestyle changes should be taken.

It takes decades for heart disease to develop, said Allan Sniderman, a McGill University cardiology professor and a co-author of the Circulation study. Excess cholesterol particles in the blood get deposited in artery walls and are surrounded by scar tissue, which damages the artery. Heart attacks occur when clumps of cholesterol break free, causing clots that obstruct the flow of blood.

Dr. Sniderman prescribed a statin drug for patient Jonathan Goldbloom when he was 34 years old, after a test showed high cholesterol. Mr. Goldbloom, of Montreal, also had a grandfather who had died at age 35 from a heart attack.

Mr. Goldbloom, now 59 and working as a crisis-communications strategist, believes the drug along with regular tennis and hockey games, gym visits and weight loss have helped him. “I’m entering the next phase of my life healthier than I would have. If I hadn’t done this, I was a likely candidate for a heart attack,” he said.

By Jonathan D. Rockoff, The Wall Street Journal
Reviewed / Posted by: Scott W. Yates, MD, MBA, MS, FACP

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