High cholesterol levels in young adults between 18 and 39 years of age increase the risk of cardiovascular disease later in life, but the use of statins to reduce cholesterol levels is currently recommended only for a small fraction of young adults who have extremely high cholesterol.
A new mathematical modeling study led by researchers at Columbia University Vagelos College of Physicians and Surgeons suggests that statins would provide lifetime health benefits for young adults with less elevated levels of low-density lipoprotein (LDL) cholesterol, preventing or delaying many heart attacks and strokes, and would be cost-effective, particularly for young adult men.
The study, led by Columbia's Andrew Moran, MD, MPH, associate professor of medicine, and Ciaran Kohli-Lynch, PhD, research scientist, was published in the Journal of the American College of Cardiology.
LDL cholesterol plays an important role in the development of atherosclerosis, the buildup of fibro-fatty plaque in the arteries and the primary cause of cardiovascular disease (heart attacks and strokes). A recent study of observational data found that, when adjusting for relevant covariates, cumulative exposure to LDL cholesterol in young adulthood substantially increases risk of later life cardiovascular events.
Clinical guidelines from the American College of Cardiology/American Heart Association currently recommend that statins only be used for cholesterol-lowering in young adults with extremely high levels of LDL cholesterol (≥190 mg/dL). Only about 2% of young adults in the United States have LDL levels that high, usually indicative of a genetic disorder that confers lifelong cardiovascular risk.
The study by Moran and colleagues examined the prevalence of elevated LDL cholesterol in the U.S. population and compared lifestyle and pharmacologic approaches to cholesterol-lowering in young adults aged 18 to 39 years.
They used a computer simulation model to assess the lifetime health effects and cost-effectiveness of initiating cholesterol-lowering treatment in a cohort of U.S. young adults-via statins or intensive programs that promote lifestyle changes-at LDL cholesterol thresholds lower than those recommended by ACC/AHA guidelines. The model synthesized evidence on the LDL cholesterol-lowering effects, side effects such as statin-induced diabetes, treatment costs, and health care costs associated with the intervention.
About 26 million young adults in the United States have an LDL cholesterol level considered borderline high or greater.
The researchers found that about 26.3 million (27%) of U.S. young adults have an LDL cholesterol level of 130 mg/dL or greater. (LDL between 130 and 160 mg/dL is considered borderline high; above 160 mg/dL is considered high).
The study predicted that cholesterol-lowering treatment could prevent three cardiovascular disease events for every 1,000 young adults initiated on lifetime treatment.
Statin therapy for young adult men with LDL cholesterol ≥130 mg/dL would cost $31,000 per quality-adjusted life year gained, while statin therapy for young adult women with LDL cholesterol ≥130 mg/dL would cost $106,000 per quality-adjusted life year gained. The American Heart Association considers treatments that cost less than $50,000 per quality-adjusted life year as "highly cost-effective," while treatments costing less than $150,000 per quality-adjusted life year are "intermediately cost-effective."
"Targeting elevated risk factors early, in young adulthood, is a new approach that has the potential to once more improve cardiovascular health in the United States and abroad."
Statin therapy was found to be more cost-effective than intensive lifestyle intervention for young adult cholesterol-lowering at all LDL cholesterol levels considered, because lifestyle modification lowers cholesterol only modestly compared with statins, and lifestyle interventions can be costly to deliver on an individual basis.
During the latter half of the 20th century, rates of cardiovascular disease fell dramatically across the high-income world thanks to an increased understanding of preventable risk factors and the development of novel cholesterol and blood pressure-lowering medications. But in recent years, cardiovascular disease rates have plateaued without improvement and 850,000 U.S. adults died from heart attacks and strokes in 2020.
"Targeting elevated risk factors early, in young adulthood, is a new approach that has the potential to once more improve cardiovascular health in the United States and abroad," Moran says.
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The article, titled "Cost-Effectiveness of Lipid-Lowering Treatments in Young Adults," was published Nov. 8 in the Journal of the American College of Cardiology.
All authors: Ciaran N. Kohli-Lynch (Columbia, Northwestern University, and University of Glasgow), Brandon K. Bellows (Columbia), Yiyi Zhang (Columbia), Bonnie Spring (Northwestern), Dhruv S. Kazi (Beth Israel Deaconess Medical Center), Mark J. Pletcher (University of California, San Francisco), Eric Vittinghoff (University of California, San Francisco), Norrina B. Allen (Northwestern), and Andrew Moran (Columbia).
The research was supported by grants from the U.S. National Heart, Lung, and Blood Institute (R01-HL107475, R01-HL141823, and K01-HL140170) and the Medical Research Council, U.K. (DTP-1522025).
Dhruv S. Kazi has received economic support from the Institute for Clinical and Economic Review for unrelated work. All other authors reported no disclosures.
