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If you were destined by your genes to have an early heart attack, would you want to know about it in your twenties?
Some people would – so they could do everything to avoid their fate, like staying a healthy weight and taking statins, cholesterol-lowering drugs.
Others may not want to know, perhaps feeling that it would be too hard to keep to a healthy lifestyle, or reluctant to take daily tablets from a young age.
Whichever side you fall on, the time when we are given the option of learning what our genes hold in store for our health is getting closer. In fact, it may arrive as soon as next year, as part of a large NHS-backed research project, called Our Future Health.
Statins still medically divisive
If the project determines that statins should be used from an early age, it is likely to be controversial. Even the current use of statins, usually for people in their forties and over, has sometimes been medically divisive.
The drugs work by reducing cholesterol levels, which slows the build-up of plaques on the walls of arteries. Such plaques can lead to heart attacks, a major cause of death in countries like the UK.
Statins were first introduced for people who’ve had a heart attack or stroke in order to stop them having a second one – a relatively uncontentious use called secondary prevention.
The controversy began when they started being offered to people who have not yet had a heart attack or stroke, in the hope of stopping it from happening – called primary prevention.
Large trials have shown this approach reduces people’s risk of a heart attack or stroke by roughly a fifth over 10 years.
But some doctors point out that statins can have side effects, like causing muscle pains, fatigue and type 2 diabetes. And some people may simply prefer not to take a tablet every day.
The debate between statin enthusiasts and their critics raged in the pages of medical journals and sometimes newspapers for several years about a decade ago.
While it still crops up, the pro-statin camp seems to have more or less won. As the NHS rolled out five-yearly health checks from the age of 40, to assess for risk of heart disease and diabetes, statins became more and more used for primary prevention.
They are now among the most commonly used daily medications, with about one in 10 adults in the UK taking them.
The case for statins in your twenties
Though the next frontier of statin use – of recommending them to people in their twenties and thirties who don’t even have high cholesterol levels yet – may prove even more divisive, there is a logic behind the approach.
Already, statins are offered from a very early age, even to children, among families who have a high risk of heart attacks because of a single genetic mutation that raises cholesterol. This genetic condition is called familial hypercholesterolaemia or FH.
But heart disease caused by a single gene is very rare. It happens more often because someone has inherited many genetic variants that each slightly raise their risk.
Working out someone’s risk of heart disease because of multiple genes involves sequencing their DNA and calculating their “polygenic risk score”, an approach that is now the cutting edge of genetic research.
Recent studies have shown that people with a heart polygenic risk score in the top eight per cent of the population have a heart attack risk just as high as people with one of the single gene FH mutations.
What’s more, if these polygenic-risk people take statins, it cuts heart attacks by roughly twice as much as it does when an average person takes them for primary prevention.
This is despite the fact that this group doesn’t have particularly high cholesterol levels – and so they wouldn’t be detected by ordinary health check tests by their GP.
“These people are wandering around at much higher risk of early heart attacks. They’re currently invisible to the system,” said Professor Peter Donnelly at the University of Oxford. “We think what’s going on is that the polygenic risk is flagging people who are more sensitive to cholesterol than average.”
These people at high polygenic risk may be “invisible” to ordinary cholesterol screening blood tests, but they are easily identified by the new breed of genetic screening tests that the NHS plans to introduce.
In the NHS Ten Year Plan, published last year, the Government announced it would make wider use of polygenic screening for a range of common conditions, starting with heart disease.
This would be done through Our Future Health, the huge public-private research project. It aims to recruit five million participants, which means it would cover a staggering one in 10 adults in England. Having launched in 2022, it is already more than halfway to this goal.
Taking part in Our Future Health involves having some basic health tests, similar to the ones done as part of the standard five-yearly health check offered to over-40s. Crucially, though, participants also give a blood sample for genetic sequencing – and recruitment is open to people aged 18 and above.
At the moment, Our Future Health is only giving feedback and lifestyle advice to participants based on their basic health statistics, like weight, blood pressure and cholesterol levels.
The i Paper understands that from next year, it will also start feeding back advice based on people’s polygenic risk scores. So, for the first time, people in their twenties and thirties, could be recommended statins if they fall into that high risk group for heart disease.
What doctors think about giving more people statins
Not all doctors welcome the move. “We don’t have any studies yet to prove the concept that giving drugs from the twenties with [high genetic risk] will lead to better outcomes 50 years later,” said Dr Scott Murray, a cardiologist at NHS University Hospitals of Liverpool Group and a former president of the British Association for Cardiovascular Prevention and Rehabilitation.
“You might expose more than 100 people to the risks with no benefits, in order to stop a heart attack in one person who responds and had disease developing,” he said.
Dr Raghib Ali, head of Our Future Health, declined to comment on the timing, but said: “Our Future Health will be working with the NHS to run a trial using integrated risk scores – which combine genetic and non-genetic data – which will offer our participants personal feedback about their health based on their lifestyle, health and genetic factors, if they wish to receive it and give their consent.”
Among many heart specialists, the plan for ever-earlier use of statins is welcomed. Professor Rory Collins at the University of Oxford, who has led statin research for the past two decades, said it would be “a major step forward in prevention of premature death and disability from cardiovascular disease”.
Donnelly, who has founded a firm called Genomics that does genetic testing for Our Future Health, said: “If you could get to these people early in life, in their twenties or thirties, and get them on statins, that’s even better than waiting till they’re forty, because you cut out any damage from the higher cholesterol for those 10 or 20 years.”
For people who don’t like the thought of taking statins from such an early age, well, they always have the option of just declining the medication. Or, perhaps, focusing on those healthy lifestyle habits.
But it seems like a preventative approach to health, rather than a reactive one, may be the future.
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