The following are key points to remember from this state-of-the-art review on managing atherosclerotic cardiovascular risk in young adults:

1. Identifying high-risk features that predict early-onset atherosclerotic cardiovascular disease (ASCVD) among young adults (ages 20-39 years) can assist providers and their patients in modifying ASCVD risk factors earlier. At-risk groups include those with tobacco use, hypertension, family history of premature coronary heart disease (CHD), severe primary hypercholesterolemia, diabetes mellitus with diabetes risk factors, and multiple major enhancing risk factors; all can benefit from intensive evaluation and treatment.
2. It is important to assess tobacco use at every young adult health care visit and provide effective intervention because the benefit of quitting before age 40 years is substantial. Smoking acts synergistically with other ASCVD risk factors, doubling the risk for CHD and stroke, tripling the risk for sudden cardiac death, and increasing the risk for peripheral artery disease five-fold. Smoking prevalence is the highest for those 25-44 years of age.
3. Smoking decreases an individual’s life expectancy by approximately 10 years. Smokers who stop before 40 years of age reduce their risk of smoking-attributable death by 90%. Counseling and pharmacotherapy have greater efficacy together than separately, but both are underused.
4. Hypertension control rates have declined in the United States in recent years. Among young adults, lack of insurance and no recent clinical visit cause a lower rate of blood pressure (BP) control. BP rises with age, and end-organ damage occurs early, even with lower BP levels.
5. Improved use of current guidelines for the measurement and treatment of hypertension among young adults is needed. Antihypertensive medication is recommended for stage 1 hypertension when lifestyle alone is ineffective. In addition, consideration for medications is important for those with a family history of premature ASCVD, a history of hypertension during pregnancy, or personal history of premature birth (all of which increase the risk for ASCVD).
6. Measurement of cholesterol early in life can identify those at increased ASCVD risk, including at least every 5 years starting at age 20. Duration of elevated low-density lipoprotein cholesterol (LDL-C) can increase ASCVD risk.
7. In young adults with LDL-C ≥160 mg/dL, the presence of a family history of premature ASCVD should lead to more intensive evaluation and statin treatment.
8. Adults with familial hypercholesterolemia (FH) should initiate statin therapy with a goal to reduce LDL-C by 50%. Once FH and/or very elevated levels of lipoprotein (a) (Lp[a]) are diagnosed, statin treatment to reduce LDL-C level screening in family members can have a significant impact beyond the individual patient.
9. Nonfasting lipids, including non–HDL-C and/or apolipoprotein B (apoB), may provide a more accurate risk assessment than LDL-C alone. They are especially useful in those with persistent hypertriglyceridemia, in whom an above-average apoB indicates heightened risk even though LDL-C levels may be below average.
10. Type 1 diabetes of ≥20 years, or type 2 diabetes of ≥10 years, and/or microvascular disease or the presence of additional ASCVD risk factors should be considered for statin therapy and modification of other risk factors.
11. Metabolic syndrome (MetS) is underdiagnosed in young adults and is related to overnutrition and insufficient physical activity. MetS is associated with the development of fatty liver, type 2 diabetes, and ASCVD. MetS doubles the risk for ASCVD. Initiation of lifestyle modification with weight loss, a heart-healthy diet, and regular aerobic exercise is the first line of therapy.
12. Current 10-year risk scores are not designed for those <40 years of age. A 30-year risk model may be preferable to discuss risk and the benefit of modifying risk factors among young adults. Clinicians are cautioned not to assess ASCVD risk by unproven adjustments to current short-term risk equations designed for those adults ages 40-75 years.
13. Risk enhancers include a family history of premature ASCVD in first-degree relatives ages <55 years in men and <65 years in women, imparting a higher lifetime than short-term risk. Ethnicity, especially South Asian ancestry, may be risk enhancing. For young women, pregnancy-related risk factors such as pre-eclampsia are early indicators of future cardiovascular risk.
14. Emerging strategies, such as coronary artery calcium (CAC) and polygenic risk scores in this age group, have potential clinical utility but whose best use remains uncertain. The presence of CAC is not common in those ages <40 years. Men with risk factors comprise a higher-risk group in whom a CAC score may convey prognostic information. Use of CAC scores should ideally occur after a clinician-patient risk discussion to put the information gained from such testing to use.
15. Barriers to risk assessment and treatment in young adults include fewer regular provider visits and thus fewer opportunities for risk assessment and modification if needed. Given that <5% of young adults in the United States adhere to all of the American Heart Association Life’s Simple 7 health behaviors, screening and identification of higher-risk young adults are of public health importance.

Clinical Topics: Arrhythmias and Clinical EP, Cardiovascular Care Team, Congenital Heart Disease and Pediatric Cardiology, Diabetes and Cardiometabolic Disease, Dyslipidemia, Prevention, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), SCD/Ventricular Arrhythmias, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Prevention, CHD and Pediatrics and Quality Improvement, Advanced Lipid Testing, Homozygous Familial Hypercholesterolemia, Hypertriglyceridemia, Lipid Metabolism, Nonstatins, Novel Agents, Primary Hyperlipidemia, Statins, Diet, Exercise, Hypertension, Smoking

Keywords: Apolipoproteins B, Atherosclerosis, Blood Pressure, Cholesterol, LDL, Coronary Disease, Death, Sudden, Cardiac, Diabetes Mellitus, Diet, Healthy, Exercise, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Hypercholesterolemia, Hyperlipoproteinemia Type II, Hypertension, Hypertriglyceridemia, Lipoprotein(a), Metabolic Syndrome, Peripheral Arterial Disease, Pre-Eclampsia, Pregnancy, Primary Prevention, Risk Assessment, Risk Factors, Smoking, Tobacco Smoking, Weight Loss, Young Adult

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