Most younger patients with premature myocardial infarction (MI) may not be identified as statin candidates before their event based on the 2018 American Heart Association (AHA) and ACC Multisociety Guideline on the Management of Blood Cholesterol, according to a study published Aug. 3 in the Journal of the American College of Cardiology. In addition, most patients with premature MI are not recommended for intensive post-MI lipid management.

Michel Zeitouni, MD, MS, et al., assessed how the 2018 ACC/AHA cholesterol guidelines changes affected identification for preventive therapy in young adults with premature MI by identifying 6,639 patients presenting with first MI at Duke University Medical Center. Statin therapy eligibility was determined using the 2013 and 2018 AHA/ACC guidelines criteria.

Result showed that 41% of study patients were younger (<55 years), 35% were middle-aged (55-65 years) and 24% were older (66-75 years). Younger patients more frequently were smokers and obese and had metabolic syndrome and higher LDL-C.

Notably, the 2018 guideline identified fewer younger adults eligible for statin therapy at the time of their MI than the 2013 guideline (46.4% vs. 56.7%; p<0.01). Younger patients were found to less frequently meet very high-risk criteria for intensive secondary prevention lipid-lowering therapy (28.3% vs. 40.0% for middle-aged vs. 81.4% for older patients, p<0.01).

Furthermore, the authors found that over a median eight years of follow-up, younger individuals with very high-risk criteria were associated with increased risk of major adverse cardiovascular events in individuals younger than 55 years (hazard ratio, 2.09; 95% confidence interval 1.82-2.41; p<0.001), as was the case in older age groups (p for interaction = 0.54).

"To our knowledge, this is among the first studies to evaluate statin guideline eligibility comprehensively with a focus on premature heart disease since the release of the most recent cholesterol guideline and implementation of risk enhancers," the authors write. "Previous studies demonstrated that older cholesterol guidelines frequently failed to assign primary prevention statins to young individuals at risk of acute MI... our results demonstrate that the situation has not improved under the 2018 guideline."

In a related editorial comment, Ron Blankstein, MD, FACC, and Avinainder Singh, MD, MMSC, note that "it is apparent that there are many more opportunities to reduce the risk of MI beyond just cholesterol-lowering agents." They add, "Ultimately, greater primordial and primary prevention efforts are needed. If our goal is to achieve the greatest possible reduction in cardiovascular events, we should not miss any opportunities to improve prevention."

Clinical Topics: Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Dyslipidemia, Prevention, Lipid Metabolism, Nonstatins, Novel Agents, Statins, Smoking

Keywords: Metabolic Syndrome, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Secondary Prevention, Cholesterol, LDL, Smoking, Cholesterol, Obesity, Primary Prevention, Myocardial Infarction, Risk Assessment

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