By Jacqueline Howard, CNN
(CNN) — Millions more adults should consider starting cholesterol-lowering medications earlier to reduce their risk of heart attack and stroke, according to new medical guidance.
In an updated guideline released Friday, the American College of Cardiology and the American Heart Association – along with nine other medical groups – emphasize that treating high cholesterol sooner, even starting in their 30s, could significantly reduce a person’s lifetime risk of heart attack or stroke.
The 123-page guideline covers many aspects of managing cholesterol and triglycerides, but one message stands out: Don’t wait too long to act.
Statin therapy is recommended, in addition to lifestyle changes like diet and exercise, for adults as young as 30 who have an LDL cholesterol of 160 milligrams per deciliter or higher, a strong family history of premature heart disease or a high 30-year risk of developing cardiovascular disease, according to the updated guideline.
“Our standard practice has been to assess 10-year risk, and statistically that will be low for a person in their 30s. But now we see a shift to 30-year risk projections,” said Dr. Jennifer Haythe, co-director of the Women’s Heart Center at NewYork-Presbyterian/Columbia University Irving Medical Center, who was not involved in the updated guidance.
“The potential benefits of starting lipid-lowering agents in younger patients are real, as there is well-supported trial data that longer duration of reduced LDL exposure translates to less plaque accumulation.”
In the United States, “there are roughly 65 to 70 million people ages 30 to 44,” she said. “So even if some small fraction of those individuals has an LDL greater than 160, the number potentially qualifying under the new criteria – with a higher 30-year risk – could be in the millions.”
Statins, some of the most commonly prescribed types of medication, work by lowering LDL cholesterol, which can build up in the arteries over time. For adults at borderline or intermediate risk, ages 30 to 79 who have started statins, the updated guideline recommends getting their LDL cholesterol down to less than 100 milligrams per deciliter of blood to prevent a first heart attack or stroke. For those at highest risk, the goal is less than 55.
Many adults with low 10-year risk but elevated 30-year risk already meet other indications for statin therapy, Drs. Pam Morris and Roger Blumenthal, authors of the updated guideline, said in an email.
“Nevertheless, incorporating a 30-year risk criterion would potentially extend consideration of statin therapy to several million additional Americans,” they wrote. “It should be noted that the risk estimates are used to identify patients who are potentially eligible for drug therapy. Subsequent steps in decision making involve consideration of patient-specific factors and the patient’s own goals for preventive therapy.”
This new shift is happening as a mounting body of research shows that reducing lifelong exposure to plaque-causing lipids and lipoproteins is associated with better long-term cardiovascular outcomes, Morris and Blumenthal said.
The updated guideline recommends using a “more contemporary” calculator to evaluate a 30- to 79-year-old adult’s cardiovascular disease risk over 10 years and 30 years: the American Heart Association’s Predicting Risk of Cardiovascular Disease EVENTs or PREVENT online calculator.
“The PREVENT-ASCVD risk estimate does not write a prescription, but it starts a conversation between the clinician and the patient. Most clinicians would likely be thinking about treating these younger men and women more aggressively because their overall burden of measured risk factors is what is driving that higher 30-year risk estimate in the first place,” Morris and Blumenthal said. “In the end, the patient makes the final decision after a clinician-patient discussion that may take place over several visits with their clinician.”
She thought she had time to wait
Gigi Gari Campos said starting cholesterol-lowering treatment earlier could have kept her from landing in a hospital bed three years ago in her early 30s. Maybe it could even have prevented, or at least delayed, the cardiac arrest that nearly took her life.
“I get goosebumps thinking about it,” said Campos, an American Heart Association volunteer advocate based in Florida. “If there was medical consensus, and every single doctor I saw would have said, ‘We know you need to start now or as soon as possible,’ then it would have been a very different journey for me.”
Growing up, Campos always knew that she was at an increased risk of cardiovascular disease because of familial hypercholesterolemia, a common, inherited genetic disorder that causes high LDL cholesterol levels from birth.
“I always knew, in my conversations with my PCP, that I was going to need to do something about my cholesterol. The thing was that the conversation always stemmed around my age and the fact that I probably had time to wait to get treatment, which in hindsight, may not have been the best choice for me,” said Campos, who’s now 37.
Her doctors were hesitant to start her on statins, she said, because she was of childbearing age. They recommended to begin treatment after having children.
The US Food and Drug Administration advises that people stop taking statins once they become pregnant, as the medication may pose a risk to the baby. Because of this, some doctors consider a more conservative approach – waiting until after a woman is finished having children to prescribe the medications.
But Campos, who was not planning to start a family, said that she did not want to keep waiting to begin treatment.
She talked with her doctor about prescribing her statins. After taking the medication for several months, her cholesterol levels were still considered high, but they were successfully lowering.
Then, she had a heart attack. She was 34 years old.
“I was on a two-mile walk with my husband. It was a beautiful, ordinary day, and about a mile into the walk, I remember telling my husband that I felt uncomfortable,” Campos said. “I felt that I had some chest pressure.”
They wondered whether the chest pressure was from sleeping awkwardly the night before.
Campos still went to work that morning, but the pressure continued for hours so she decided to drive to urgent care. Tests revealed she had an unusual heart rhythm, and the urgent care medical team called for an ambulance to transport Campos to a nearby hospital.
At the hospital, doctors found that Campos needed a cardiac catheterization, a minimally invasive procedure to find blockages in the heart and then remove them.
As they started to prep her for the procedure, she went into cardiac arrest.
“I remember the nurse asking me if I felt OK. I remember saying I felt OK, but I just felt faint. And that’s when they said that I looked like I was clearly having a heart attack,” Campos said. “My eyes rolled back, and thankfully they were able to cardiovert me or shock my heart back to life. I remember waking up and realizing that everything was very, very tense in the room. I remember thinking, ‘All I got is a little prayer.’ So, I remember doing two ‘Our Fathers,’ before I went into cardiac arrest a second time.”
The hospital team was still able to complete the procedure, Campos said, and the blockages in her heart were cleared.
Potential benefits to starting earlier
Heart disease is the leading cause of death in the United States and it’s estimated that one person dies from cardiovascular disease every 34 seconds.
The updated guideline will affect millions more adults in the United States who have high cholesterol, said Dr. Steven Nissen, chief academic officer of the Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute at Cleveland Clinic in Ohio, who was not involved in the updated guidance but has been a longtime critic of ACC/AHA guidelines.
“This refocus on at least giving some thought to the lifetime risk is very important because we know that the time-averaged LDL cholesterol over your lifetime is one of the strongest predictors of whether you’re going to have a heart attack, stroke or sudden death, and they are really acknowledging that in the guidelines,” Nissen said.
“Also, if you start early, you may not need to treat as intensively. Because if you start early, you can reduce your time-averaged lifetime LDL cholesterol, without necessarily having to treat with a very high dose of statin,” he said.
Some possible side effects of statin medications include muscle pain, muscle weakness or liver damage, which may be more likely at higher doses.
“I see a lot of people where I put them on an entry dose of a statin at a young age, knowing that they’re going to get the accumulating benefit of time. And that’s kind of a nuance, but it’s an important nuance about earlier treatment,” Nissen said. “In this case, they’ve now really moved the guidelines to where I think they should have been all along.”
Since Campos’ heart attack, she said she has resumed taking statins nightly without having any side effects. She also takes two other medications and has focused on eating a healthy diet, exercising regularly – and spending time with family.
“Being in that bed in ICU, after having my heart attack and seeing all of my loved ones around me was very hard, because you realize that you’re not in this world just for yourself. You’re here for all of them,” Campos said. “You’re here because you have a bigger purpose.”
Campos said that she has reduced her total cholesterol from being around 400 milligrams per deciliter at the time of the cardiac arrest to now being less than 100.
“And my LDL, which is that ‘bad’ cholesterol, is in the 20s. I live a full life with these levels, and it’s giving me comfort knowing that I’m doing everything that I can,” Campos said.
“The most important thing is to educate yourself and know that whatever treatment options you choose, if you don’t hit those lower levels, you are increasing your chance of ending up with a heart event,” she said. “For me, it was truly life and death.”
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