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General practitioners often overlook screening for cardiovascular disease (CVD) risk factors in young adults. But new information from the Coronary Artery Risk Development in Young Adults (CARDIA) study suggests a link between moderately elevated heart disease risk factors as early as 18 years of age and an increased risk of coronary calcium later in life.1 Coronary artery calcium (CAC) is a predictor of coronary events in asymptomatic adults.
CARDIA researchers investigated how well risk factor levels measured at intervals of 2–5 years over 15 years could predict coronary calcium in the 15th and final year, according to co-author Cora Lewis, MD, professor of medicine at University of Alabama at Birmingham.
The study followed 5,115 white and African-American adults after their enrollment in the study, at ages 18–30 years, in 1985 and 1986. The researchers measured factors believed to be related to heart disease, such as smoking, LDL cholesterol, body mass index (BMI), blood pressure, and blood glucose levels in years 0, 2, 5, 7, 10, and 15.
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During the last year, participants underwent two computed tomography scans to assess the presence of CAC. Overall, 9.6% of the adults had detectable CAC, with greater prevalence in men, in older participants, and in white men compared with African-American men.
"We found increased CAC presence in those people exhibiting less than optimal risk factor levels, but still well under the level where guidelines would suggest aggressive treatment," Lewis says. "We now understand that you can take young adults in their 20s and get an idea as to who is going to develop atherosclerosis at a faster rate."
IDENTIFY EARLY CVD RISK
The results underscore the importance of evaluating CVD risk factors in young people, says lead author Catherine Loria, PhD, a nutritional epidemiologist at the National Heart, Lung, and Blood Institute of the National Institutes of Health. "If a young adult has even slightly elevated [risk factor] levels, the physician may want to encourage lifestyle changes to reduce their patient's risk."
Young adults with above-optimal levels for each of the risk factors at baseline were two to three times more likely to have measurable CAC in the future. In addition, increases in coronary artery calcium in the 40–45 age group, compared with the 33–39 age group, suggest an acceleration of the development of CAC in later years.
Specifically, the researchers found those with blood glucose >110 mg/dl had a threefold increase in risk of developing CAC deposits by year 15; those with LDL cholesterol >130 mg/dl had a twofold increase in risk; and those with blood pressure >120/80 mmHg at entry had a 1.5–2 times greater risk.
Given the correlations between risk factors and CAC, Loria suggests primary care physicians conduct more cholesterol, blood pressure, BMI, and blood glucose screening for CVD risk factors in younger patients.
"National data would suggest that fewer people in this age group undergo risk-factor screening than older adults," Loria says. "We don't necessarily do a great job of making sure that we look for CVD risk factors in our patients who appear healthy."
TAKE ACTION
If screening reveals high CVD risk in young patients, physicians should advise them to improve their diets and exercise regularly, says Deanna Willis, MD, an associate professor of family medicine at Indiana University School of Medicine in Indianapolis who was not involved with the study.
Willis concedes, though, that it's "a challenge to convince patients that eating bar-and-grill food in [their] 20s really impacts their heart later on."
Another challenge is determining when or if to initiate treatment with medications in young adults, notes Lewis.
"This is an observational study, so we don't have the clinical trial
data needed to show you should be treating this group with medications,
especially from an early age," Lewis says. "The things we can do
without trial data are strongly encourage healthy diet and lifestyle at
earlier ages, and not think all is well because your patient is under
30." 
Footnotes
Clinical practice guidelines on screening for and managing high cholesterol, high blood pressure, and obesity are available from the National Heart, Lung, and Blood Institute at www.nhlbi.nih.gov/guidelines/index.htm.
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