Currently, the decision of whether to start someone on a statin largely hinges on a calculation of their 10-year risk of having a heart attack or stroke. It considers many factors, including age, sex, race, blood pressure, smoking, diabetes, and individual goals. But this approach by itself doesn’t capture younger adults who might benefit from more aggressive lipid-lowering now to prevent future disease even 30 years later.
Experts say this is an important question because damage to the artery walls, which ultimately sets the stage for a heart attack or stroke, starts relatively early in life. Also, nearly half of these heart attacks or strokes occur before age 65.
In this study, published in Circulation, researchers sought to determine the benefits of early versus delayed lipid-lowering therapy in preventing cardiovascular disease over 30 years as predicted by two models. They used two models to predict the effect of lowering low-density lipoprotein (LDL) or “bad” cholesterol early. Both models demonstrated greater benefits with earlier lipid lowering, especially in people with higher levels of non-high-density lipoprotein (non-HDL) cholesterol, which is a person’s total cholesterol minus their "good" cholesterol. It reflects all the "bad" types of cholesterol.
Based on the findings, the authors write, “for many, the question of when to start lipid lowering might be more relevant than whether to start lipid lowering.” Such an approach also shifts the focus from stabilizing disease that is already present to trying to prevent damage and disease earlier and, perhaps, before it starts.
The study included data from 3,148 participants in the National Health and Nutrition Examination Survey (NHANES) who were 30 to 59 years old, did not have heart disease, and would not be eligible for statin therapy under the most recent U.S. guidelines. Researchers grouped participants by age (30-39 years, 40-49 years and 50-59 years) and non-HDL cholesterol levels.
In general, reductions in heart disease were predicted to be greater among those who were older and had higher non-HDL cholesterol. According to the analysis, people 40 to 49 years old with a non-HDL cholesterol greater than 160 ml/dL who are started on a statin would be expected to lower their average predicted risk of developing cardiovascular disease by as much as 17%. So, despite the low 10-year risk among study participants, it seems many would benefit from intensive lipid lowering to include lifestyle changes and starting a statin rather than delaying therapy, authors said.
The authors conclude that, “Substantial reduction in expected atherosclerotic disease risk in the next 30 years is achievable by intensive lipid-lowering in individuals in their 40s and 50s, with non-HDL greater than or equal to 160 mg/dL.” They also note that “personalized treatment decisions should be made based on individual estimates of risk and potential treatment benefit.”
While more work needs to be done, this study should give rise to more research and discussions about the need to focus on ways to lower cardiovascular risk earlier in one’s life before disease or damage to the arteries begins.
Visit CardioSmart.org/Prevention for more information about how to prevent heart disease.