January 22, 2019
In the second installment of this series, Amit Khera, MD, director of Preventive Cardiology and a Professor of Medicine at UT-Southwestern Medical Center in Dallas, discusses lifestyle risk, long-term risk, and genetic cholesterol problems among younger patients and he explains why it is important to screen earlier in life.
This is Dr. Amit Khera. I am Director of Preventive Cardiology and a Professor of Medicine at UT‑Southwestern Medical Center in Dallas. I'm also President of the American Society of Preventive Cardiology.
The last thing I'll talk about is something I would like to call lifestyle risk, long‑term risk, and genetic cholesterol problems. There are some genetic cholesterol problems, one is called familial hypercholoesterolemia. It affects about 1 in 250 people in the population.
It's inherited in an autosomal‑dominant manner, meaning if you have it, you have 50/50 chance of giving it to your children. It's a 50/50 chance of passing it on. These people have pretty high cholesterol from birth, and they have about a 5‑ to 16‑fold increase risk of heart attacks and strokes in their lifetime.
The guidelines did a couple of things. First, they reminded us that heart disease is a lifelong illness. When people have a heart attack at age 60, heart disease begins in our teens and even in childhood. It's a lifelong prevention plan.
Now they specifically said that we should think about this lifetime. In people who are 20 to 40, we should counsel them and check their cholesterol and talk about their lifetime risk, in terms of their long‑term risk.
Mainly statins are recommended in people over the age of 40. Even 20 to 40, it doesn't mean they all need medicine, but we shouldn't ignore them either. If the cholesterol's high, we predominantly focus on lifestyle things, diet and exercise.
The current recommendation if you're a parent, have high cholesterol or early heart disease, children are supposed to get their cholesterol checked as early as the age of two. That sounds a little extreme, but the goal there is to pick up people who might have familial hypercholesterolemia.
As I mentioned, it 1 in 250 people. It's not terribly rare. If we can pick it up in childhood and starting treatments like statins earlier in life ‑‑ FDA‑approved at the age of 10 for kids that have this severe cholesterol issue ‑‑ then we may have an opportunity to really change these people's natural history.
The take‑home points on that part of the guideline is this idea let's not just wait till 40 to think about heart disease. Even in people 20 to 40, we should be having these conversations and paying attention to the risk factors.
In some people with very high cholesterol, we need to identify other family members and screen them for genetic cholesterol problems. The earlier we impact them and start medicines, we can greatly reduce the risk of heart attacks and strokes over their lifetime.
I hope that was informative and helpful for your work with patients in preventing heart disease and strokes.