Ron Blankstein

Heart attacks among adults younger than 50 are on the rise. In fact, the proportion of very young people has been rising by 2 percent each year for the last decade, according to a team of Brigham investigators studying this alarming trend to help prevent heart attacks in the first place.

In a paper published this month in the Journal of the American College of Cardiology, the team reports on the prevalence of familial hypercholesterolemia (FH), a genetic disorder that results in high cholesterol, and outcomes for patients affected by it. Investigators found that nearly one in 10 patients who suffer a first heart attack before age 50 had FH, and many still had elevated cholesterol levels a year later. Meanwhile, many were not previously on a statin therapy, highlighting opportunities for prevention and more aggressive treatment for those at risk.

“One of the challenges of familial hypercholesterolemia is that it is under-recognized and undertreated,” said corresponding author Ron Blankstein, MD, a preventative cardiology specialist and associate director of the Cardiovascular Imaging Program. “Only about half of the FH patients in our study were on a statin therapy before their first heart attack, and many were not treated aggressively following their event. Intervening to lower cholesterol could mean preventing not only subsequent heart attacks but first heart attacks, too.”

Examining the Data

Blankstein and colleagues collected data on all patients at the Brigham and Massachusetts General Hospital who had suffered a heart attack before age 50 between 2000 and 2016. Using the Dutch Lipid Clinic (DLC) Criteria — one of most commonly used ways to screen for FH — the team identified those patients with the disorder and used electronic medical records to determine cardiovascular risk factors as well as what medications the patients had been taking prior to their heart attack and what medications were prescribed at discharge.

Blankstein and colleagues found that nearly one in 10 young adults who had suffered a heart attack met the clinical definition for FH. Of those who had elevated LDL cholesterol (greater than or equal to 160 mg/dL), that proportion increased to four out of every 10. And among those who had both family history of premature coronary artery disease and high cholesterol, the proportion was six in 10. On average, FH patients had LDL cholesterol levels of 180 mg/dL at the time of their heart attack, and 43 percent were not on a statin therapy. An LDL level of less than 100 mg/dL is considered desirable for most adults.

Following their first heart attack, only 49 percent of FH patients were prescribed a high-density statin therapy. One year after their heart attack, most of the overall patient population had elevated cholesterol levels, with 43 percent having cholesterol levels greater than 100 mg/dl and 82 percent having cholesterol levels above 70 mg/dl.

Over 11 years of follow-up, 10 percent of FH patients died.

The team notes that the underutilization of high-intensity statin therapy after a first heart attack was not unique to FH patients, and that there are opportunities for more aggressive lipid-lowering therapy for young patients with or without the disorder.

“It’s important for both providers and patients to be aware of the significant benefit associated with reducing cholesterol. It’s important to do so after a heart attack, but even before, if a patient has risk factors. We know that more aggressive treatment of cholesterol and other risk factors can be very effective for avoiding a heart attack in the first place,” said Blankstein. “There is also an enormous need to improve other risk factors. In this study, we find clinically defined FH in only one in 10 young patients who have had a heart attack. Other factors beyond FH seem to play a much larger role in explaining why individuals in our study cohort experienced a myocardial infarction at a young age.”

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