Non-diabetic women under the age of 40 and men under the age of 50 who do not smoke and do not have hypertension are at low risk for atherosclerotic cardiovascular disease (ASCVD) and might not benefit from regular cholesterol screening, according to an analysis published May 15 in the Annals of Internal Medicine.

The 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults recommend lipid screening for all adults older than 20 years of age. In addition, statins may be considered for patients with an estimated 10-year ASCVD risk greater than 5 percent, followed by repeat testing every 4 to 6 years to identify those at high risk for ASCVD. In contrast, the 2008 guideline from the United States Preventive Services Task Force (USPSTF) recommends that screening start at 35 for men and 45 for women unless at least one risk factor is present. 

Krishna K. Patel, MD, et al., sought to assess the prevalence of elevated ASCVD risk in non-diabetic adults under the age of 50 in order to determine which guideline recommendation to follow. Researchers estimated the 10-year ASCVD risk from a cross-section of 9,608 participants from the National Health and Nutrition Examination Survey using the 2013 ACC/AHA ASCVD risk estimator. Participants were divided into subgroups by age, sex, and history of smoking and hypertension.

The results of the analysis show that in the absence of smoking or hypertension, .09 percent of men under 40 and .04 percent of women under 50 had an elevated risk of ASCVD. Overall, 9.1 percent of participants had a 10-year estimated ASCVD risk greater than 5 percent. Further, only 1.7 percent had an LDL-C level of at least 4.92 mmol/L (190 mg/dL), and they “were no more likely to report a family history of premature heart attack than those with lower LDL-C levels.”

Given the low prevalence of patients at elevated cardiovascular risk, the researchers suggest following the more targeted approach of the USPSTF guidelines. “However, given the observed risk distribution, screening for adults without risk factors might begin at age 40 years for men and 50 years for women,” they conclude.

In an accompanying editorial comment, Paul M. Ridker, MD, MPH, FACC, and Nancy R. Cook, ScD, note that the analysis “has substantive limitations … including the fact that the data are cross-sectional and that no actual clinical events were recorded.” They add that, “the primary analysis excluded all persons younger than 50 years who were receiving statins or who had already had a major vascular event. Yet, these persons very likely had a strong family history or elevated cholesterol levels – exactly the group the authors sought to identify. [Further,] those concerned with the primary prevention of cardiovascular disease should advocate for early-life LDL-C evaluation, not a delayed approach.”

Neil J. Stone, MD, FACC, vice chair of ACC’s Guideline on Cholesterol Writing Committee, adds that the study “supports a strategy that misses a chance to make a life-saving diagnosis of familial hypercholesterolemia and also, importantly, to start a quantitative guideline-recommended clinician-patient risk discussion early in life, with the potential to make a difference by endorsing lifestyle changes that can reduce the large risk factor burden for heart attack and stroke present  in this country.”

Keywords: Adult, Atherosclerosis, Cardiovascular Diseases, Cholesterol, Cross-Sectional Studies, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Hypercholesterolemia, Hypertension, Lipids, Myocardial Infarction, Nutrition Surveys, Prevalence, Primary Prevention, Research Personnel, Risk Factors, Smoke, Smoking

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