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Cholesterol screening in young adults requires targeted approach

In the absence of smoking or hypertension, women younger than 40 years and men younger than 50 years have a minimal risk of atherosclerotic cardiovascular disease and may not benefit from regular cholesterol screening as recommended by the American College of Cardiology and American Health Association guidelines, according to research published in Annals of Internal Medicine.

Rather, these findings suggest that clinicians use a more targeted approach to cholesterol screening as advised by the U.S. Preventive Services Task Force, according to the researchers.

“Elevated cholesterol levels have been long known to be a strong risk factor for cardiovascular disease, myocardial infarction and stroke,” Krishna K. Patel, MD, from the University of Missouri-Kansas City, and colleagues wrote. “Screening for dyslipidemia can identify asymptomatic individuals at risk for atherosclerotic [CVD], allowing them to pursue lifestyle interventions or medical therapy.”

However, there are conflicting guidelines on screening for dyslipidemia. In 2013, the American College of Cardiology and American Heart Association (ACC/AHA) recommended that all adults aged 20 years or older receive an initial lipid panel and undergo repeated testing every 4 to 6 years to identify individuals at high risk for atherosclerotic CVD. In contrast, the USPSTF recommended in 2008 that initial screening be performed at age 35 years for men and age 45 years for women unless one or more atherosclerosis risk factors are present. Patel and colleagues evaluated which guideline should be followed, as well as the prevalence of increased atherosclerotic CVD in adults under the age of 50 years.

They conducted a cross-sectional analysis of the National Health and Nutrition Examination Surveys from 1990 to 2000 and 2011 to 2012 including 9,608 participants (representing 67.9 million adults) aged 30 to 49 years without known atherosclerotic CVD or diabetes who were subdivided by age, sex and history of smoking and hypertension. About half of participants were in low-prevalence subgroups, defined as those in which a greater than 1% prevalence of increased cardiovascular risk could be ruled out.

A 10-year estimated atherosclerotic CVD risk greater than 5% was prevalent in 9.1% (95% CI, 8.3-9.9) of participants. The researchers found that only 0.09% (95% CI, 0.02-0.35) of adult men younger than 40 years and 0.04% (95% CI, 0-0.26) of women younger than 50 years who do not smoke or have hypertension had an elevated risk of atherosclerotic CVD. In addition, LDL cholesterol levels of 4.92 mmol/L or greater were observed in 2.9% of participants.

“Given the low prevalence of patients at elevated cardiovascular risk, our findings would support the targeted approach of the USPSTF over the more general screening of the ACC/AHA,” Patel and colleagues concluded. “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.”

In a related editorial, Paul M. Ridker, MD, MPH, and Nancy R. Cook, ScD, both from Brigham and Women’s Hospital, argued that this study had several limitations that may significantly alter the effective screening rates, such as use of cross-sectional data, no record of clinical events and exclusion of individuals younger than 50 years who were receiving statins and who had already experienced a major vascular event.

“Absence of evidence is not evidence of absence,” they wrote. “We disagree with the USPSTF recommendation to delay lipid screening until mid-adulthood simply because clinical trial evidence is not available in younger persons. Rather, we believe that at least 1-time LDL [cholesterol] screening should be universally recommended for all patients in their late teen or early adult years. If anything, we support the principled biologic approach promoted by the American Academy of Pediatrics, which recommends that all children be screened for high cholesterol levels at least once between the ages of 9 and 11 years, and again between ages 17 and 21 years.”

“Those concerned with the primary prevention of cardiovascular disease should advocate for early-life LDL [cholesterol] evaluation, not a delayed approach,” Ridker and Cook concluded. – by Alaina Tedesco

Disclosures: Patel and colleagues and Cook report no relevant financial disclosures. Ridker reports receiving grants from AstraZeneca, Novartis, Kowa and Pfizer, as well as personal fees from Pfizer, AstraZeneca.