Young Patients With Premature ASCVD Less Likely to Receive Statins, Aspirin

Not only are younger patients with premature or extremely premature atherosclerotic cardiovascular disease (ASCVD) less likely to be prescribed statins and aspirin, but also these patients are less likely to stick with statins when compared to older adults with the condition, according to a large analysis of patients treated within the US Department of Veterans Affairs (VA) system.

Senior investigator Salim Virani, MD, PhD (Michael E. DeBakey VA Medical Center, Houston, TX), said the findings suggest that while younger patients may be resistant to starting or staying on these lifelong medical therapies, there is also some “clinical inertia” with respect to prescribing medical therapy when ASCVD develops in younger patients.  

“I think some of this might be related to the physicians,” he told TCTMD. “When you see a young patient with atherosclerotic cardiovascular disease, they don’t look quite as bad despite having a similar disease as older patients. They might be more functional. In our study, the traditional cardiovascular risk factors that one would ascribe to cardiovascular disease, the prevalence was a little bit lower in younger patients with ASCVD.”

As a result, clinicians may underestimate the risk of younger patients even though they are just as much in need—and may even derive a greater lifelong benefit—of guideline-directed medical therapy with statins and aspirin, among other agents.

“Of course, there is also the whole side of the patient who thinks of their disease as not being so bad,” said Virani. “When we’re young, we all have this optimism bias.” That optimism bias, where younger patients might not have a full grasp of the seriousness of the disease, also can foster suboptimal statin adherence, as evidenced in the analysis, he said.

Stressing Disability to Younger Patients

The new study, which was published online August 20, 2020, in JAMA Network Open with lead author Dhruv Mahtta, DO (Michael E. DeBakey VA Medical Center), included 1,248,158 patients enrolled in the nationwide Veterans With Premature Atherosclerosis (VITAL) registry. Of these, 10.9% were considered to have premature ASCVD, which was defined as the first event occurring in men and women younger than 55 and 65 years, respectively. The mean age of people with premature ASCVD was 49.6 years, which was 20 years younger than the mean age of the nonpremature ASCVD group. Extremely premature ASCVD, documented in 7,716 patients (0.6%), was defined as a first event occurring in those younger than 40 years.

In terms of medication, 71.1% of patients in the premature ASCVD group were prescribed aspirin compared with 77.4% of those with nonpremature ASCVD (P < 0.001). Similarly, just 72.9% of these younger patients received a statin compared with 80.5% of those in the nonpremature group (P < 0.001). Patients with premature ASCVD were more likely to be treated with a high-intensity statin compared with those with nonpremature disease (36.4% vs 29.9%; P < 0.001), but in general, the younger patients were less likely to be adherent to any statin therapy. Just 57.9% of those with premature ASCVD had a “proportion of days covered” of at least 0.8, reflective of good adherence to statins, compared with 72.0% of patients with nonpremature ASCVD.  

For the patients with extremely premature ASCVD, the picture was even bleaker. Overall, fewer than half of these patients received aspirin or a statin (47.5% and 45.7%, respectively), just 22.7% were prescribed a high-intensity statin, and only 52% were adherent to any statin therapy.  

To TCTMD, Virani said the optimism bias among young patients can persist even after an ASCVD event. “They may think, ‘I’m going to do much better because I’m young and this was probably just a onetime event and I was unlucky,’” he said.

Virani stressed that the study is a reminder to clinicians about the importance of guideline-directed medical therapy in secondary prevention, including for people with premature and extremely premature ASCVD. Regardless of age, patients with a prior event should be flagged through the electronic medical record for high-intensity statin therapy, as well as aspirin, he said. However, therapy only works if patients take the prescribed medication.

“In this case, providing physicians with tools in terms of how to approach a young patient is important,” he said. “For young patients, apart from telling them that we’re giving this therapy so that they don’t have another heart attack, that’s important and should be discussed, but for a young patient it might be more important to discuss disability. If you have a stroke at a young age, that’s going to bring a lot of disability. Talking more about the impact of events on their functional capacity, and the number of years they may have to live with disability, especially if they have young family, might be a better conversation.”

Virani also emphasized keeping the tone of that conversation positive, stressing to patients that statins and aspirin are effective therapies with an excellent long-term safety profile.

“We want to make sure we understand what the patient is concerned about when taking these therapies,” he said. “Traditionally, when we talk about pill burden, we think about our older patients who have a lot of medical problems and who are on a lot of drugs. I think the same may hold true for younger patients because a lot of them are young and busy.” Following an MI or PCI, patients can end up taking five or six medications, Virani said, so physicians need to work with patients by prescribing only drugs they absolutely need and help them understand how taking those medications can fit into their lives.