Association between lipid fractions and age of first myocardial infarction.

OBJECTIVE: Dyslipidemia is a major cause of early coronary heart disease (CHD). Low-density-lipoprotein cholesterol (LDL-C), remnant cholesterol (remnant-C) and high-density lipoprotein cholesterol (HDL-C) have all been shown to be associated with risk of CHD. We aimed to compare the association of these lipid fractions with age at first myocardial infarction(MI). Design. Multicenter study of consecutive patients hospitalized with a first MI. Linear regression models were used to assess the independent association of LDL-C, remnant-C and HDL-C with age at first MI. Results. The study included 1744 patients. In univariate analyses, LDL-C, remnant-C, and HDL-C were all significantly associated with age at first MI. However, in multivariate analyses only LDL-C [-2.5 years (95%CI: -3.1 to -1.8) per 1 SD increase] and to a lesser extent remnant-C [-0.9 years (95% CI: -1.5 to -0.3)] continued to be associated with age of MI, while HDL-C [0.5 years (95%CI: -0.2 to 1.2)] was not. Conclusions. LDL-C is the lipid fraction strongest associated with younger age of presentation of first MI. These results support the importance of controlling and treating LDL-C in prevention of premature MI.

Statin use and cardiovascular risk factors in diabetic patients developing a first myocardial infarction.

BACKGROUND: The risk for a first myocardial infarction (MI) in people with diabetes has been shown to be as high as the risk for a new MI in non-diabetic patients with a prior MI. Consequently, risk-reducing statin therapy is recommended for nearly all patients with diabetes 40 years of age or older, regardless of cholesterol level. The purpose of this study was to assess the recommended and real-life use of statins for primary prevention of atherosclerotic cardiovascular disease (ASCVD) in diabetic patients who develop ASCVD. METHODS: In a cross-sectional multicenter study of consecutive patients without previous ASCVD hospitalized with a first MI in 2010-2012, we obtained information on diabetic status, statin use, and cardiovascular risk factors prior to MI. RESULTS: The study population consisted of 1622 patients with first MI (63 % men), 228 of whom had known diabetes before MI. All but three of the diabetic patients were ≥40 years of age. Diabetic patients were older (70 vs 68, p = 0.006), were more often women (43 vs 36 %, p = 0.05) and had a higher prevalence of statin use (47 vs 11 %, p < 0.001) compared with non-diabetic patients. Despite a high risk factor burden, the majority (53 %) of patients with known diabetes was not treated with statins before MI, and there was no relationship between the number of high-risk markers and statin use. Nearly all diabetic patients not treated with statins before first MI had at least one marker of very high cardiovascular risk, including hypertension (71 %), current smoking (37 %), and nephropathy (33 %). CONCLUSIONS: Primary prevention with statins had been initiated in less than half of diabetic patients destined for a first MI, despite the presence of one or more markers of very high cardiovascular risk in nearly all. These results highlight an urgent need for optimizing statin therapy and global risk factor control in diabetic patients.

Statin use prior to first myocardial infarction in contemporary patients: Inefficient and not gender equitable.

OBJECTIVES: Guidelines recommend initiating primary prevention with statins to those at highest cardiovascular risk. We assessed the gender-specific implementation and effectiveness of this risk-guided approach. METHODS: We identified 1399 consecutive patients without known cardiovascular disease or diabetes hospitalized with a first myocardial infarction (MI) in Denmark. Statin use before MI was assessed, and cardiovascular risk was calculated using SCORE (Systematic COronary Risk Evaluation). RESULTS: Among patients with first MI, 36% were women. Compared with men, they were older (mean 72 vs. 65years) but had a lower estimated risk (median 3.4% vs. 6.7%, SCORE high-risk model in the statin-naïve patients). Statin therapy had been initiated in 12% of women and 10% of men prior to MI. After adding 1.5mmol/L to the total cholesterol concentration of those already on statins, the estimated pre-treatment risk was much lower in women than men (median 3.8% vs. 9.2%, SCORE high-risk model), and only 29% of women would have passed the risk-based treatment threshold defined by the European guidelines (SCORE ≥5%). Estimated risk and statin use correlated directly in men but not in women. Only ~5% of first MI are prevented by the current use of statins in people without diabetes. CONCLUSION: In people destined for a first MI, statin therapy is uncommon and prevents few events. Lower-risk women receive as much statins as higher risk men. This gender disparity and inefficient targeting of statins to those at highest risk indicate that risk scoring is not widely used in routine clinical practice in Denmark.

Familial hypercholesterolemia among unselected contemporary patients presenting with first myocardial infarction: Prevalence, risk factor burden, and impact on age at presentation.

BACKGROUND: Familial hypercholesterolemia (FH) is a hereditary disease carrying a substantial lifetime risk of coronary heart disease. OBJECTIVE: To assess the prevalence of FH and its impact on age at presentation among unselected patients with first myocardial infarction (MI). METHODS: In a multi-center cross sectional study, we identified 1381 unselected patients presenting with a first MI between 2010 and 2012. Clinical FH was assessed using both the Dutch Lipid Clinic Network (DLCN) criteria and the Simon Broome criteria. RESULTS: Based on the DLCN criteria, 2.0% of patients with first MI had "probable/definite" FH, whereas 4.7% had "possible" FH according to the Simon Broome criteria. In the 291 (21%) patients with premature MI, 6.9% had "probable/definite" FH (DLCN criteria), and 11.0% had "possible" FH (Simon Broome criteria). Nearly all premature "probable/definite" and "possible" FH patients had at least one additional marker of high cardiovascular risk including current smoking (72%-80%) and hypertension (40%-44%). In multivariable-adjusted linear regression modeling, patients with "probable/definite" FH using DLCN criteria had their first MI 14.6 years (95% confidence interval [CI], 9.6-19.6 years) earlier than non-FH patients. Likewise, "possible" FH patients using Simon Broome criteria were associated with having an MI 9.1 years (95% CI = 6.3-12.4) earlier than non-FH patients. CONCLUSION: Clinical FH is common and associated with markedly earlier age of first MI, especially when combined with additional markers of high risk, indicating an unmet need for earlier identification of FH to ensure global risk factor control. First MI constitutes a unique opportunity to detect families with unknown FH.