Hypercholesterolemia Not Adequately Managed in Younger Adults
Key findings
- This was a registry study that examined data from 2005 through 2019 on 17,951 patients diagnosed with hypercholesterolemia at age 20 to 39 in a large health care system composed of multiple academic and community-based practice sites
- Only 30% of the 5,438 patients with severe hypercholesterolemia achieved guideline-directed ≥50% reduction in low-density lipoprotein cholesterol (LDL-C), and 23% had an LDL-C level persistently 190 mg/dL or greater
- 48.5% of patients with severe hypercholesterolemia were prescribed lipid-lowering therapy
- Of the 12,513 patients with moderate hypercholesterolemia, only 20% received lipid-lowering therapy and only 36% showed at least a 30% reduction in LDL-C
- Women with severe hypercholesterolemia were less likely than men to have ≥50% LDL-C reduction, and women with either moderate or severe hypercholesterolemia were less likely than men to receive lipid-lowering therapy
Epidemiologic studies have established that the accumulation of low-density lipoprotein cholesterol (LDL-C) in early life increases the risk of future cardiovascular disease, independent of cholesterol exposure in midlife and cumulative exposure. Unfortunately, a recent real-world study documents inadequate management of hypercholesterolemia in younger adults.
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Shauna L. Newton, MD, an internal medicine resident at Massachusetts General Hospital, Michael C. Honigberg, MD, MPP, cardiologist at the Corrigan Minehan Heart Center at Mass General, and colleagues report the details in a research letter published in JAMA Cardiology.
Methods
The team consulted clinical registry data from seven Mass General Brigham hospitals and affiliated community practices. They searched for patients who had cholesterol tested between 2005 and 2018, when they were 20 to 39 years old, and had an LDL-C value qualifying as hypercholesterolemia. The 17,951 patients identified were divided into two cohorts:
- Cohort 1, severe hypercholesterolemia—5,438 patients (30%) had LDL-C ≥190 mg/dL
- Cohort 2, moderate hypercholesterolemia—12,513 patients (70%) had LDL-C of 160 to <190 mg/dL
All patients had at least one more LDL-C measurement during the follow-up period, which extended through December 31, 2019. Median follow-up was 7.8 years for cohort 1 and 7.7 years for cohort 2.
Results for Cohort 1
- Lipid-lowering therapy was prescribed for only 48.5% of patients
- 30% of patients achieved the guideline-recommended ≥50% reduction in LDL-C; 78% had received lipid-lowering therapy
- Women were less likely than men to receive lipid-lowering therapy (44% vs. 52%; P<0.001) and less likely to have a ≥50% reduction in LDL-C (27% vs. 32%; P<0.001)
- Younger individuals were less likely to achieve a ≥50% reduction in LDL-C (age 20–24 years, 25%; age 35–39, 33%; P<0.001 for trend)
- At last follow-up, 23% of patients still had LDL-C ≥190 mg/dL
Results for Cohort 2
- Lipid-lowering therapy was prescribed for only 20% of patients (15% of women and 23% of men; P<0.001)
- 36% of patients showed a ≥30% reduction in LDL-C (no significant difference between women and men)
- At last follow-up, 30% of patients still had LDL-C ≥160 mg/dL
Opportunities to Improve Care
This study highlights the need to incorporate guideline-recommended cholesterol management strategies into the care of younger adults.
In particular, the findings suggest many clinicians underestimate the risks associated with persistent moderate hypercholesterolemia in younger adults. Current guidelines recommend aggressive lifestyle modification and consideration of statin therapy in adults 20 to 39 years old who have LDL-C levels of 160 to <190 mg/dL plus other high-risk features such as a family history of cardiovascular disease.
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