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Should we be measuring blood cholesterol levels in young adults?
S B Hulley1, T B Newman, D Grady
1Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco 94143.
Insights
Routine cholesterol screening for young adults is not cost-effective or ethically justified. Focus on middle-aged individuals for coronary heart disease (CHD) prevention, reserving screening for high-risk young adults.
Area of Science:
- Cardiovascular Health
- Preventive Medicine
- Public Health Policy
Background:
- Coronary heart disease (CHD) risk is very low in adults under 35 (men) and 45 (women).
- Current screening and treatment policies for high cholesterol in young adults warrant re-evaluation.
- The cost-effectiveness and ethical implications of widespread cholesterol intervention in young populations are debated.
Purpose of the Study:
- To evaluate the necessity and efficacy of measuring blood cholesterol levels in all adults versus only those at high risk for CHD.
- To assess the cost-effectiveness and potential harms of cholesterol interventions in young adults.
- To determine optimal strategies for cholesterol management and CHD prevention across different age groups.
Main Methods:
- Analysis of primary prevention trials in middle-aged men.
- Meta-analysis of cholesterol intervention studies.
- Cost-effectiveness evaluation of cholesterol treatment strategies.
Main Results:
- Drug treatment for young adults is extremely expensive per year of life gained ($1M-$10M).
- Meta-analysis revealed an increase in non-CHD deaths with cholesterol interventions in middle-aged men.
- Potential for serious adverse effects from cholesterol interventions in young adults outweighs benefits due to their low short-term CHD risk.
Conclusions:
- Screening and treating high cholesterol in young adults is not cost-effective and lacks ethical justification based on current evidence.
- Most CHD events linked to high cholesterol in young adults can be prevented by initiating treatment in middle age.
- Cholesterol screening in young adults should be reserved for those with existing coronary disease or other specific high-risk factors.
Abstract:
Should we measure blood cholesterol levels in all adults, or only in those at high risk of coronary heart disease (CHD)? Most men under the age of 35 years and women under the age of 45 years--roughly half the adult population--are at very low short-term risk of CHD. One consequence is that drug treatment to lower high blood cholesterol levels in the average young adult is an extremely expensive means of prolonging life; the estimated $1 million to $10 million per year of life is 100 to 1000 times the cost of other approaches. Individualized dietary treatment is somewhat cheaper but relatively ineffective. Another consequence of the low CHD risk in young adults is the greater likelihood that intervention may have harmful effects that outweight the benefits. Meta-analysis of primary prevention trials in middle-aged men reveal an increase in non-CHD deaths among those randomized to cholesterol interventions, an unexpected finding that is more substantial than the decrease in CHD deaths. This raises the possibility that one or more of the cholesterol interventions could have very serious adverse effects among young adults, whose risk of non-CHD death is normally 100 times their risk of CHD death. We conclude that the policy of screening and treating high blood cholesterol levels in young adults is neither cost-effective, nor does it satisfy ethical standards requiring strong evidence that preventive interventions do more good than harm. Fortunately, cholesterol screening in young adults is also not necessary: most CHD events associated with high blood cholesterol levels in this population will not occur for decades and can be prevented by treatment that is begun in middle age. Cholesterol screening and treatment in young adults should be limited to individuals with known coronary disease or other unusual factors that place them at high short-term risk of CHD death.