Key result
The 2018 AHA/ACC very high-risk criteria linked to ~2.1-fold higher recurrent post-MI events in young adults.
Why the study?
The 2018 AHA/ACC cholesterol guideline updated statin eligibility criteria and added novel intensive lipid-lowering therapies, but the impact of these changes on identifying young adults with premature MI for preventive therapy needed to be determined.
Does the 2018 AHA/ACC cholesterol guideline improve the identification of young adults (<55 years) for primary prevention statin therapy prior to premature myocardial infarction and intensive secondary prevention therapy compared to the 2013 ACC/AHA guideline?
Cohort (n=6,639)
No
Does the 2018 AHA/ACC cholesterol guideline improve the identification of young adults (<55 years) for primary prevention statin therapy prior to premature myocardial infarction and intensive secondary prevention therapy compared to the 2013 ACC/AHA guideline?
The 2018 AHA/ACC cholesterol guideline fails to identify more than half of young adults (<55 years) for primary prevention statin therapy prior to their first myocardial infarction and recommends fewer than 30% for intensive secondary prevention lipid-lowering therapy.
Answers are grounded in this paper and cite their sources.
2018 guidelines may miss more young adults for pre-MI statins; leaves open refinement of very high-risk criteria for secondary prevention in premature MI.
Background The 2018 AHA/ACC cholesterol guideline changed statin eligibility criteria for primary prevention to include multiple risk enhancers and novel intensive lipid-lowering therapies for secondary prevention. Objectives Determine how guideline changes impacted identification for preventive therapy in young adults with premature myocardial infarction (MI). Methods We identified adults presenting with first MI at Duke Hospital; statin therapy eligibility was determined using the 2013 ACC/AHA and 2018 AHA/ACC guidelines criteria. We also determined potential eligibility for intensive lipid-lowering therapies (very high risk) under the 2018 AHA/ACC guidelines, assessing the composite of all-cause death, recurrent MI, or stroke rates in adults considered “very high risk” vs. not. Results Among 6,639 MI patients, 41% were <55 years (“younger”), 35% were 55–65 (“middle-aged”), and 24% were 66–75 (“older”). Younger adults were more frequently smokers (52% vs. 38% vs. 22%), obese (42% vs. 34% vs. 31%), with metabolic syndrome (21% vs. 19% vs. 17%), and higher low-density lipoprotein cholesterol (117 vs. 107 vs. 103 mg/dL); p-trend <0.01 for all. Pre-MI, fewer younger adults met guideline indications for statin therapy than middle-aged and older adults. The 2018 guideline identified fewer younger adults eligible for statin therapy at the time of their MI than the 2013 guideline (46.4% vs. 56.7%, p<0.01). Younger patients less frequently met very high-risk criteria for intensive secondary prevention lipid-lowering therapy (28.3% vs. 40.0% vs. 81.4%, p<0.01). Over a median 8 years of follow-up, very high-risk criteria were associated with increased risk of major adverse cardiovascular events in individuals <55 years (HR 2.09, 95% CI 1.82–2.41, p<0.001), as was the case in older age groups (p-interaction=0.54). Conclusions Most younger patients with premature MI are not identified as statin candidates prior to their event based on the 2018 guidelines and most with premature MI are not recommended for intensive post-MI lipid management.
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Zeitouni et al. (2020) conducted a cohort in First acute myocardial infarction with angiographically-proven obstructive coronary artery disease (n=6,639). 2018 AHA/ACC guideline very high-risk criteria for future ASCVD vs. Not meeting very high-risk criteria was evaluated on Composite of all-cause death, non-fatal recurrent myocardial infarction, or stroke in younger patients (<55 years) (HR 2.09, 95% CI 1.82-2.41, p=<0.001). The 2018 AHA/ACC guideline identified fewer adults <55 years for pre-MI statins than 2013 (46.4% vs 56.7%, p<0.01), while very high-risk criteria predicted recurrent events (HR 2.09, p<0.001).
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