Adults under the age of 40 years with raised low-density lipoprotein cholesterol (LDL-C) are far less likely than older adults to be prescribed a statin, even though their age means that the potential benefits of taking a statin are much greater, researchers based in the United States have found.
The team at University Hospitals Cleveland Medical Center, Ohio, discovered that less than 45% of adults under the age of 40 years with an elevated LDL-C level of 190mg/dL or greater (equivalent to 4.9mmol/L or above) received a prescription for a statin.
However, the researchers point out that statins are recommended for any adult aged at least 21 years with an LDL-C level of 190mg/dL or greater, because raised levels may indicate familial hypercholesterolemia and a heightened risk of cardiovascular disease and death.
The researchers used data from a national registry to examine rates of statin prescription in patients aged between 20 and 75 years who were screened for dyslipidemia across 360 medical centres and who had both LDL-C and pharmacy records reported between 1 July 2013 and 31 July 2016.
The authors found that of the 2,884,260 patients with a qualifying lipid analysis, 109,980 (3.8%) had an LDL-C of 190mg/dL or greater. Pharmacy records showed that across all age groups, 41,750 (66%) of patients with severe dyslipidaemia but without diabetes or established atherosclerotic cardiovascular disease (ASCVD) were prescribed a statin. This rose to 183,740 (69%) in patients with diabetes but not ASCVD, and 207,050 (68%) for patients with ASCVD but without diabetes.
The researchers also found that one in four patients (25%) with extremely severe elevations of LDL-C (greater than 250mg/dL) were not being prescribed a statin. Women were also less likely to be prescribed a statin.
Most notably, the results show that statin prescription dropped sharply in younger age; they were prescribed in 32%, 47% and 61% of patients in their 30s, 40s, and 50s, respectively, with less than 45% of patients under the age of 40 years receiving a statin.
Resporting their findings in a research letter in JAMA Cardiology
(online, 4 January 2017), the researchers say: “This finding has particular relevance given the early onset of ASCVD and cardiovascular death observed in familial hypercholesterolemia studies from the pre-statin era.
“For this reason, for patients with primary LDL-C elevation level of 190mg/dL or greater and who are 21 years or older, current guidelines recommend against the use of an ASCVD risk calculation, which could inappropriately lead to deferral of statin therapy for these high-risk patients
,” they add.
“Specific interventions that optimise the follow-up of younger patients after lipid screening may be needed to realise the potential for improved survival and cost reduction associated with the treatment of severe dyslipidemia.”
Commenting on the study on behalf of the British Cardiovascular Society, a membership organisation for UK cardiologists, Kausik Ray, professor of public health at Imperial College London, says: “The study reinforces two key trends seen globally that women and younger people are less likely to get treatment.”
He adds that risk calculators are partly responsible for this because they look at only ten-year risk rather than lifetime risk. “A person aged 35 [years] has many more life years to gain from treatment than someone aged 75 [years]. These data reflect problems with using only short term risk, physician knowledge and patient perceptions of their own risk.”
Ray adds that someone with LDL-C greater than 190mg/dL “usually should not have ten-year risk calculated as many of them have genetic dyslipidemia. As such they should be considered for therapy”.
 Knowles JW, Stone NJ & Ballantyne CM. Familial hypercholesterolemia and the 2013 American College of Cardiology/American Heart Association guidelines: myths, oversimplification, and misinterpretation versus facts. American Journal of Cardiology 2015;116(3):481-484. doi: 0.1016/j.amjcard.2015.04.062