Trends in management of cardiovascular risk factors in young adults who go on to develop coronary artery disease
Authors: Vikulova D , Lee M , Pinheiro Muller D , Pimstone S , Brunham L 
Published: October 2022

Abstract

Background
Rates of premature coronary artery disease (CAD) have remained stagnant in many countries in the past two decades. While guidelines on cardiovascular prevention are evolving to improve risk assessment, more data are needed to evaluate changes in risk management in younger patients with high cardiovascular risk.

Purpose
To investigate the trends in pre-presentation prevalence and management of major cardiovascular risk factors (CVRFs) and predictors of initiation of lipid-lowering therapy (LLT) in patients with premature coronary artery disease.

Methods
In this retrospective cohort study, we identified women &lt;55 years old and men &lt;50 years old who presented with obstructive CAD (stenosis &gt;50% or history of coronary revascularization) between 2000 and 2017. Data were collected from administrative databases and provincial cardiac information system and included demographics, all outpatient visits, hospitalizations, pharmacy dispenses in the period of 3 years prior to CAD, presentation characteristics, and results of invasive coronary angiography.

Results
In total, 14,470 patients (29.7% females) met the study criteria. During the study period, prevalence decreased for dyslipidemia and smoking and increased for hypertension, diabetes and obesity (Figure 1). Over 96.5% of patients were eligible for lipid screening 3 years prior to presentation with CAD, 93.5% had visits with primary care physicians, and 57.4% had visits with specialist physicians. Only 20.5% received LLT, with rates rising from 19% in the year 2000 to 24% in 2017 (p=0.023). Additionally, 38.1% of patients received medical treatment for other CVRFs. Figure 2 presents risk management and rates of LLT initiation in patients with five major CVRFs. In multivariable logistic regression analysis, LLT was more likely in patients with diabetes (odds ratio [OR] 3.04, 95% CI 2.74–3.36), hypertension (OR 1.44, 95% CI 1.30–1.58), chronic kidney disease (OR 1.79, 95% CI 1.44–2.23), and depression (OR 1.25, 95% CI 1.11–1.40). Later year of presentation (OR 1.04, 95% CI 1.03–1.05), older age at presentation (OR 1.03, 95% CI 1.02–1.04) and residing in urban areas vs rural (OR 1.36, 95% CI 1.16–1.58) were also positively associated with LLT. Male sex (OR 0.88, 95% CI 0.78–0.98) and smoking (OR 0.68, 95% CI 0.62–0.76) were associated with lower likelihood of treatment. Obesity, hypothyroidism, chronic inflammatory conditions, and malignancies were not significantly associated with LLT.

Conclusion
Despite the rising prevalence of CVRFs, high eligibility for lipid screening, and availability of care, rates of LLT initiation in patients who go on to develop premature CAD remain very low, representing a major missed opportunity for cardiovascular disease prevention. Many of the major CVRFs and risk enhancers endorsed in current guidelines were not associated with treatment initiation, suggesting that new approaches may be required to increase appropriate use LLT in these patients.

Funding Acknowledgement
Type of funding sources: Foundation. Main funding source(s): St. Pauls Hospital Foundation, Vancouver, BC, CanadaVancouver General Hospital Foundation, Vancouver, BC, Canada