By Antje Schmidt-Pogoda, Fachärztin für Neurologie, Klinik für Neurologie mit Institut für Translationale Neurologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149 Münster
Only recently, the treat stroke to target trial has demonstrated the benefit of aggressive LDL-cholesterol lowering for secondary stroke prevention.1 Depending on the overall cardiovascular risk and LDL-cholesterol levels, Current European Society of Cardiology (ESC) and European Atherosclerosis Society (EAS) guidelines also recommend LDL-cholesterol lowering for primary prevention of cardiovascular disease.
However, in young and otherwise healthy people, cholesterol levels are rarely determined. If increased, would this be worth worrying anyway?
A recent risk-evaluation and risk-modelling study from the Multinational Cardiovascular Risk Consortium sheds light on this important issue: Worrying about cholesterol is in fact worth it – even at young age.2 The study included data from almost 400 000 individuals with a maximum follow-up of 43.6 years (median 13.5). The mean age of participants was 51 years with one third at age<45 years. The primary composite endpoint of atherosclerotic cardiovascular disease was defined as the occurrence of a coronary heart disease event or ischemic stroke.
The study results show progressively higher 30-year cardiovascular disease event rates for increasing non-HDL-cholesterol categories (from 7·7% for non-HDL-cholesterol <2·6 mmol/L to 33·7% for ≥5·7 mmol/L in women and from 12·8% to 43·6% in men; p<0·0001).
In women, a non-HDL value of 2.6 to 3.7 mmol/l was associated with a 10% increase in long-term risk of cardiovascular disease. The hazard ratio was significant with a 95% confidence interval of 1.0 to 1.3. A non-HDL value of over 5.7 mmol/l increased the long-term risk by 90% (hazard ratio 1.9; 1.6 to 2.2) and was most marked at age<45 years (hazard ratio 4.3; 3.0-6.1).
The risk was similar for men: the hazard ratios were 1.1 (1.0 to 1.3) for non-HDL cholesterol from 2.6 to 3.7 mmol/l and 2.3 (2.0 to 2.5) for a non-HDL value of over 5.7 mmol/l. Again most prominent at age<45 years (4.6, 3.3-6.5)!
These long-term calculations show that younger people are at risk even with slightly elevated cholesterol levels. The authors attribute this to an accumulating effect. Altogether, these findings pronounce that elevated non-HDL-cholesterol levels should be taken seriously in the young.
- Amarenco P, Kim JS, Labreuche J, Charles H, Abtan J, Bejot Y, et al. A comparison of two ldl cholesterol targets after ischemic stroke. N Engl J Med. 2019
- Brunner FJ, Waldeyer C, Ojeda F, Salomaa V, Kee F, Sans S, et al. Application of non-HDL cholesterol for population-based cardiovascular risk stratification: results from the Multinational Cardiovascular Risk Consortium. Lancet. 2019