Statin Eligibility of Young Adults After MI: YOUNG-MI Registry

Study Questions:

Among young adults who experience a myocardial infarction (MI), how many would have been eligible for statin therapy prior to their MI?

Methods:

Data from the YOUNG-MI registry, a retrospective cohort study, were used for the present analysis. This cohort includes patients who experienced an MI, were 50 years of age or younger, and who received care from two large academic hospitals in Boston, MA, between 2000 and 2016. Only type 1 MIs were included; all events were adjudicated by study physicians. MI type was based on the Third Universal Definition of MI. Individuals with known coronary artery disease (defined as prior MI or revascularization) were excluded. Individuals were also excluded if they had missing values for lipid profiles or systolic blood pressure, which are necessary components for the Pooled Cohort Equations for estimation of cardiovascular risk and hence determination of statin eligibility. In addition, patients who were on statin therapy prior to MI were also excluded. Pooled cohort risk equations were used to estimate atherosclerotic cardiovascular disease (ASCVD) risk score based on data available prior to MI or at the time of presentation. The presence of cardiovascular risk factors (hypertension, dyslipidemia, family history, diabetes, smoking, and obesity) was ascertained by a detailed review of electronic medical records during or before the index admission.

Results:

A total of 1,475 adults were included, median age was 45 years, 294 (20%) were women, and 1,060 (72%) were white. Over half (57%) were admitted with an ST-segment elevation MI. The majority of patients (83%) had at least one risk factor, with dyslipidemia (present in 55% of patients) being the most common. Smoking was present in 52% and hypertension was present in 44% of the cohort. Among the patients with dyslipidemia, 163/818 (20%) had no prior history of this condition and were first diagnosed during the index hospitalization for MI. Similarly, diabetes and hypertension were first diagnosed in 55/246 (22%) and 61/649 (9%) patients, respectively. The median 10-year atherosclerotic cardiovascular disease risk score of the cohort was 4.8% (interquartile range: 2.8, 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 United States 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%) of men (p < 0.001).

Conclusions:

The authors concluded that the 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.

Perspective:

These data suggest that identification of methods, perhaps including coronary artery calcium scoring, may improve current risk prediction methods for young adults. It should also be noted that the majority had at least one cardiovascular risk factor; thus, efforts to reduce smoking and hypertension in young adults would likely translate into diminished risk. Last, the majority of patients in this cohort were white – additional research is warranted in minority populations.

Clinical Topics: Acute Coronary Syndromes, Congenital Heart Disease and Pediatric Cardiology, Diabetes and Cardiometabolic Disease, Dyslipidemia, Prevention, CHD & Pediatrics and Arrhythmias, CHD & Pediatrics and Prevention, CHD & Pediatrics and Quality Improvement, Lipid Metabolism, Nonstatins, Novel Agents, Statins, Hypertension, Smoking

Keywords: Acute Coronary Syndrome, AHA17, AHA Annual Scientific Sessions, Atherosclerosis, Blood Pressure, Coronary Artery Disease, Diabetes Mellitus, Dyslipidemias, Electronic Health Records, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Hypertension, Lipids, Middle Aged, Myocardial Infarction, Obesity, Primary Prevention, Risk Assessment, Risk Factors, Smoking, Young Adult


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