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Current guidelines underestimate statin eligibility after MI in young adults

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ANAHEIM, Calif. — The majority of adults who present with MI at age 50 years or younger did not meet current guideline-based treatment thresholds for statin therapy before their MI, according to new data from the retrospective YOUNG-MI registry.

“The vast majority of young adults would not have met current guideline-based [statin] treatment thresholds despite a high prevalence of traditional cardiovascular risk factors, and a significantly greater proportion of women were not eligible for statin therapy prior to their MI compared with men,” Avinainder Singh, MBBS, postdoctoral research fellow at Brigham and Women’s Hospital, said during a presentation at the American Heart Association Scientific Sessions.

Singh and colleagues analyzed data from the YOUNG-MI registry, a retrospective cohort study from Brigham and Women’s Hospital and Massachusetts General Hospital that includes patients who experienced an MI at age 50 years or younger from 2000 to 2016. The current analysis focused on 1,475 patients. In this group, the median age was 45 years, 20% were women, 57% had STEMI and 83% presented with at least one CV risk factor. Seventeen percent of patients were younger than 40 years at the time of MI. Those prescribed statin therapy before admission for MI were excluded from the analysis.

Statin eligibility was determined using the 2013 American College of Cardiology/AHA guidelines for treatment of blood cholesterol and the 2016 U.S. Preventive Services Task Force (USPSTF) recommendations for statin use in primary prevention.

“[The guidelines] use different thresholds,” Singh said. “The ACC/AHA guideline uses a threshold of 7.5%, whereas the USPSTF guideline uses a threshold of 10%. In addition, [both guidelines] require the presence of one cardiovascular risk factor.”

In the entire cohort, the median 10-year atherosclerotic CVD (ASCVD) risk score was 4.8%, ranging from 2.8% to 8%.

Based on the ACC/AHA guidelines, 49% of patients would have met criteria for statin eligibility. Following this guidance, 31% would have met criteria for initiation of statin therapy prior to MI, 18% would have met criteria for consideration of statin therapy and 51% would not have been eligible for primary prevention, according to the findings.

Based on the USPSTF recommendations, 29% would have met criteria for statin eligibility. Following these recommendations, 18% would have met criteria for statin initiation prior to MI, 11% would have met criteria for statin consideration and 71% would not have been eligible for statin therapy, according to the findings.

Further, only 50% of patients would have met criteria for statin eligibility after applying both the ACC/AHA and the USPSTF recommendations. Twenty-three percent of patients with at least three CV risk factors would not have been eligible for statin therapy using the ACC/AHA guideline and 43% using the USPSTF recommendations.

Commenting on the findings, Deepak L. Bhatt, MD, MPH, chief medical editor of Cardiology Today’s Intervention, executive director of interventional cardiovascular programs at Brigham and Women’s Hospital Heart & Vascular Center, and professor of medicine at Harvard Medical School, said the researchers “found that a substantial proportion of patients who should have been on statins were not ... but even more interesting was that the substantial proportion would not have met current eligibility criteria for statins, which means that the current risk calculators and other metrics we have to gauge risk aren’t accurate or perfect or even ideal in young people.

“Young people with atherosclerosis isn’t a population from which these risk calculators were derived, so there tends to be an underestimation of risk,” Bhatt told Cardiology Today.

The researchers also reported significant differences in statin eligibility between young men and women. Overall, only 37% of women would have been eligibility for statin therapy based on either guideline, compared with 54% of men.

“Our findings imply that the low ASCVD risk score may be falsely reassuring in some young adults, especially those who have risk factors,” Singh said. “There is a need to recalibrate existing risk scores or perhaps develop novel approaches for risk prediction among young adults.”

According to Bhatt, based on these data, the CV prevention community has to “do a better job to identify young people at risk and, when appropriate, target pharmacotherapy.” – by Darlene Dobkowski, with additional reporting by Katie Kalvaitis

References:

Singh A, et al. Ancel Keys Memorial Lecture: Lifestyle and Medical Therapy for CVD Prevention. Presented at: American Heart Association Scientific Sessions; Nov. 11-15, 2017; Anaheim, California.

Singh A, et al. J Am Coll Cardiol. 2017;doi:10.1016/j.jacc.2017.11.007.

Disclosures: Singh reports no relevant financial disclosures. Bhatt reports he has financial ties with Amarin, Amgen, AstraZeneca, Biotronik, Boston Scientific, Bristol-Myers Squibb, Cardax, Chiesi, Eisai, Eli Lilly, Ethicon, FlowCo, Forest Pharmaceuticals, Ironwood, Ischemix, Lilly, Medtronic, Merck, Pfizer, PLx Pharma, Regado Biosciences, Roche Diagnostics, Sanofi Aventis and The Medicines Company.