More young people should be getting their cholesterol tested and taking statins

For busy primary care physicians like me, an annual physical with a 27-year-old male is a blessing. Since we’re always running late, a quick visit with a young healthy adult offers the rare chance to get back on schedule.

But I didn’t give my own doctor that chance to get back on schedule when I went to see him for my physical a few months ago.

After the customary interview and exam, just as he was ready to leave, I asked him to check my cholesterol. National guidelines from professional medical societies — which primary care physicians usually follow — recommend routine cholesterol testing for men starting at age 35. I wanted to get checked early because my dad, like more than 100 million other Americans, has high cholesterol and there is a strong hereditary component. A high level of low-density lipoprotein (LDL), aka bad cholesterol, increases the risk of heart attack and stroke.

After a long discussion, he granted my request. When we received the results, we were both surprised to see my LDL was at the upper limit of the normal range. We discussed my diet and exercise habits, which are reasonably good, and scratched our heads about what to do next. The conventional teaching about treating high cholesterol is to use a risk calculator that incorporates cholesterol levels, age, blood pressure, and other data to predict a patient’s individualized cardiovascular risk. The U.S. Preventive Services Task Force and the American College of Cardiology recommend using a specific calculator that estimates an individual’s risk of having a heart attack or stroke over the next 10 years. Most guidelines suggest starting a statin — a commonly used medication for lowering cholesterol — when that risk exceeds 7.5%.

But when my doctor and I tried to compute my risk, we got an error message. It turns out that the widely endorsed calculator can provide estimates only for people between the ages of 40 and 75.

Young adults are often excluded from studies of cardiovascular risk because heart attacks are less common under age 40. As a result, evidence on cholesterol and statins in young adults is lacking, which makes it difficult for national committees and professional societies to write useful guidelines that apply to us.

These gaps in clinical guidelines have consequences for clinical practice. Despite estimates that more than half of young adults in the U.S. have LDL levels high enough to increase their lifetime cardiovascular risk, only about 40% have had their cholesterol checked in the last five years. Most concerning, only one-fifth of young adults with high cholesterol were aware they had it.

Under-checking is compounded by under-treating. There’s no debate that individuals with LDL levels above 190 should be on a cholesterol-lowering medicine, but according to a 2022 study, less than half of such individuals in their 20s and 30s are prescribed a statin. The same study also found that, unsurprisingly, fewer than 1 in 3 young adults with high cholesterol achieve the guideline-recommended reductions in their LDL level.

These data suggest that our health care system is shortchanging young people like me and putting us at higher risk of preventable heart disease later in life.

As we tried to figure out what to do about my cholesterol, my doctor and I discovered four reasons (though there may be many more) to be more aggressive about screening and treating high cholesterol in young adults than current guidelines dictate.

One: There is overwhelming evidence that high cholesterol is not just correlated with coronary artery disease — it causes coronary artery disease, and the relationship is dose-dependent. More LDL means a higher risk of heart attack, and mounting data show that lower is better even at levels well within the “normal” range. As one cardiologist told me, “LDL is a toxin — just get rid of it.”

Two: An individual’s risk for having a heart attack or stroke is driven by cumulative exposure to LDL over time. Plaque starts to develop in the coronary arteries during the teenage years and accumulates over decades. Because cumulative exposure is what matters, high LDL in a 30-year-old man poses far greater lifetime risk than high LDL that develops in his late 60s.

Three: Researchers are discovering that some groups — especially people of South Asian heritage, like me — get heart attacks at younger ages than others. For reasons that are still being uncovered, South Asian men are also more likely to die from heart attacks than white men. If, as the current guidelines stipulate, screening for high cholesterol starts at age 35 and treatment starts at age 40 (for most people), we doctors are missing countless opportunities to save lives in at-risk populations.

Four: Statins — the first-line therapy for high cholesterol — are highly effective at lowering LDL and reducing cardiovascular risk. They are also safe. To be sure, some people experience side effects. But the common ones, like muscle pain, are straightforward to detect and manage. Statins have also been linked to a slightly increased risk of diabetes, but the actual effect on blood sugar levels is quite modest and especially safe for people who are young and otherwise healthy. Statins are also inexpensive. The out-of-pocket cost can be as low as just a few dollars per month. Studies show that treating young adults in the U.S. whose LDL levels exceed 130 (far below the currently recommended threshold of 190) with statins would be highly cost-effective, yielding significant improvements in longevity at bargain prices, even after factoring in the risk of side effects like statin-induced diabetes.

To realize these benefits, the U.S. Preventive Services Task Force and the American College of Cardiology need to revisit their national guidelines around screening and treating cholesterol in young adults. (I tried reaching out to both groups, but did not hear back.) By reducing the age at which doctors begin checking cholesterol levels, millions of young adults with high LDL who, under current guidelines, don’t get the full picture of their cardiovascular risk until much later, could be identified.

Efforts to increase screening should be paired with a lower threshold to discuss medications for young adults with high cholesterol.

I’m not the first to suggest this.

In fact, some experts in the U.S. have already begun calling for the USPSTF and ACC relax the 40-year age threshold for statins. And in January, the National Health Service in England proposed liberalizing its eligibility requirements for statins, making an additional 15 million people eligible independent of their calculated cardiovascular risk.

Some may argue that guidelines should not be revised without randomized controlled trials that specifically study the long-term effects of statins in young adults over their lifetimes. Such studies would be incredibly valuable, but they are challenging to conduct for many reasons, including the sheer number of people — possibly tens of thousands — who would need to be recruited and followed for a long time. In the absence of the data we would like, we have to make do with what we have, and the preponderance of evidence makes a strong case for the benefits of keeping LDL lower for longer.

Others contend that young adults with high cholesterol should make lifestyle changes before starting medications. But this view overlooks that much of one’s cardiovascular risk is genetic — meaning lifestyle modifications can only take you so far — and ignores the reality that a healthy diet and frequent exercise are not equally accessible or achievable for everyone.

The final decision to start any medication requires a discussion between physician and patient. In my case, we concluded that the benefits of starting a statin outweighed the risks. I suspect the same is true for thousands of other young people, and I hope they have similar conversations with their doctors.

I will certainly be doing so with my own patients.

Suhas Gondi is a resident physician in internal medicine and primary care at Brigham and Women’s Hospital. The views expressed here are his and do not necessarily represent those of his employers.