Cardiovascular Risk and Statin Eligibility of Young Adults After an MI: Partners YOUNG-MI Registry

Abstract

Background: Despite significant progress in primary prevention, the rate of MI has not declined in young adults.

Objectives: The purpose of this study was to evaluate statin eligibility based on the 2013 American College of Cardiology/American Heart Association guidelines for treatment of blood cholesterol and 2016 U.S. Preventive Services Task Force recommendations for statin use in primary prevention in a cohort of adults who experienced a first-time myocardial infarction (MI) at a young age.

Methods: The YOUNG-MI registry is a retrospective cohort from 2 large academic centers, which includes patients who experienced an MI at age ≤50 years. Diagnosis of type 1 MI was adjudicated by study physicians. Pooled cohort risk equations were used to estimate atherosclerotic cardiovascular disease risk score based on data available prior to MI or at the time of presentation.

Results: Of 1,685 patients meeting inclusion criteria, 210 (12.5%) were on statin therapy prior to MI and were excluded. Among the remaining 1,475 individuals, the median age was 45 years, there were 294 (20%) women, and 846 (57%) had ST-segment elevation MI. At least 1 cardiovascular risk factor was present in 1,225 (83%) patients. The median 10-year atherosclerotic cardiovascular disease risk score of the cohort was 4.8% (interquartile range: 2.8% to 8.0%). Only 724 (49%) and 430 (29%) would have met criteria for statin eligibility per the 2013 American College of Cardiology/American Heart Association guidelines and 2016 U.S. Preventive Services Task Force recommendations, respectively. This finding was even more pronounced in women, in whom 184 (63%) were not eligible for statins by either guideline, compared with 549 (46%) men (p < 0.001).

Conclusions: The vast majority of adults who present with an MI at a young age would not have met current guideline-based treatment thresholds for statin therapy prior to their MI. These findings highlight the need for better risk assessment tools among young adults.

Keywords: myocardial infarction; prevention; risk; statin; young adults.

FIGURE 1. Prevalence of Cardiovascular Risk Factors Stratified by Statin Eligibility

Distribution of the most common risk factors within our cohort, stratified by the proportion of patients who are recommended (blue), considered (gray), or not recommended (orange) to use statins by the 2013 American College of Cardiology/American Heart Association guidelines. CAD = coronary artery disease.

FIGURE 2. Lifetime Cardiovascular Risk

Proportion of patients with high lifetime cardiovascular risk (≥39%) among young adults with myocardial infarction.

FIGURE 3. Burden of Risk Factors and Statin Ineligibility

Proportion of patients not eligible for statin therapy stratified by cumulative burden of cardiovascular risk factors by 2013 ACC/AHA (blue) and 2016 USPSTF (orange) recommendations. *Cardiovascular risk factors considered include diabetes, hypertension, dyslipidemia, and smoking. ACC/AHA = American College of Cardiology/American Heart Association; USPSTF = U.S. Preventive Services Task Force.

FIGURE 4. Statin Eligibility of Young Adults Prior to Myocardial Infarction by Various Guidelines

The square represents the total population (n = 1,475) of patients who experienced a myocardial infarction at a young age. The colored circles represent the proportion of statin eligible (statins considered/statin recommended) individuals. The size is directly proportional to magnitude of statin eligibility, with the 2013 ACC/AHA guidelines (blue), 2016 USPSTF recommendations (orange), and NCEP III guidelines (gray). Overlap between circles represents individuals that were eligible by multiple respective guidelines. NCEP = National Cholesterol Education Panel; other abbreviations as in Figure 3.

FIGURE 5. Sex Differences in Statin Eligibility

Classification of statin eligibility by the 2013 ACC/AHA guidelines (blue) and 2016 USPSTF recommendations (orange) for women (left) and men (right). Abbreviations as in Figure 3.

CENTRAL ILLUSTRATION. Guideline-Based Statin Eligibility of Young Adults Prior to MI

Contemporary statin guidelines were applied to 1,475 young adults not on statins prior to myocardial infarction. (Left) The stepwise implementation of the 2013 American College of Cardiology/American Heart Association cholesterol guidelines. (Right) The stepwise implementation of the 2016 United States Preventive Services Task Force statin recommendations. The cohort is stratified by statin eligibility according to specified guideline criteria into 3 groups: statin recommended (green), statin considered (gray), and statin not recommended (orange). The risk factors considered by USPSTF guidelines include diabetes, hypertension, dyslipidemia, and smoking. ACC/AHA = American College of Cardiology/American Heart Association; ASCVD = atherosclerotic cardiovascular disease; CV = cardiovascular; LDL = low-density lipoprotein; MI = myocardial infarction; USPSTF = U.S. Preventive Services Task Force.