Younger adults (men 20-35 years; women 20-45 years)
In this age group, CHD is rare except for persons with severe risk factors, e.g., familial hypercholesterolemia, heavy cigarette smoking, and diabetes. Even though clinical CHD is relatively rare in young adults, coronary atherosclerosis in its early stages may be progressing rapidly. The rate of development of coronary atherosclerosis in young adulthood has been shown to correlate with the major risk factors. Long-term prospective studies further note that elevated serum cholesterol first observed in young adults predicts a higher rate of premature CHD in middle age. Thus, risk factor control in young adults represents an attractive aim for primary prevention.
ATP III recommends testing for lipids and lipoproteins beginning at age 20. There are several reasons for this recommendation. First, early testing provides physicians with the opportunity to link clinical management with the public health approach to primary prevention; the finding of any risk factors in their early stages calls for the reinforcement of the public health message. Second, every young adult has the right to be informed if they are at risk for the development of premature CHD, even though clinical disease may be several decades away. Third, individuals with cholesterol levels in the upper quartile for the population are definitely at higher long-term risk, and life-habit intervention to control risk factors is fundamental.
Most young adults with very high LDL-cholesterol levels (≥190 mg/dL) are candidates for cholesterol-lowering drugs, even when they are otherwise at low risk with 0-1 risk factor and 10-year risk <10 percent. Although their 10-year risk may not be high, long-term risk will be high enough to justify a more aggressive approach to LDL lowering. ATP II set a higher cutpoint for initiation of cholesterol-lowering drugs (LDL cholesterol ≥220 mg/dL) in young adults than is being recommended in ATP III. The apparent safety of cholesterol-lowering drugs and growing evidence of the dangers of early onset LDL-cholesterol elevations have led the ATP III panel to recommend consideration of cholesterol-lowering drugs at an LDL cholesterol of ≥190 mg/dL in young adults. However, prudence in the initiation of cholesterol-lowering drugs is still indicated. In otherwise low-risk young adults it is acceptable to maximize TLC and to delay initiation of cholesterollowering drugs when the LDL cholesterol is in the range of 190 to 220 mg/dL, particularly in premenopausal women. Through the use of LDL-lowering dietary options, possibly combined with bile acid sequestrants, elevated LDL cholesterol in young adult men before age 35 and in premenopausal women usually can be normalized.
In young adults with LDL <190 mg/dL, ATP III guidelines applied to all adults are appropriate. Favorable changes in life habits should receive highest priority for management of elevated LDL cholesterol in young adults. Because of long-term risk, judicious use of drug therapy may be warranted in those who have LDL levels of 160-189 mg/dL and other risk factors. Nonetheless, the high costs and potential for side effects in the long term must always be kept in mind when considering cholesterol-lowering drugs.
