The child is father to the man

Not Surprising, But Important

Zhang and co-authors pooled data from six US cohort studies to examine the effect of risk factors in young adulthood (age 18–39 years) and older adulthood (>40 years) on cardiovascular events. They did not actually have risk factor data for all participants from age 18 years onward because few studies have followed and repetitively measured risk factors over the lifespan, so the authors used data from the six studies to calculate expected low density lipoprotein cholesterol (LDL-C) and systolic (SBP) and diastolic blood (DBP) pressures for subjects at age 18 years and older. Risk factor patterns from studies with older subjects were used to impute future risk factors for young subjects, and risk factor patterns from studies with young subjects were used to impute previous risk factors for older subjects. The results are based on 36,030 participants followed for a median of 17 years. The authors’ methodology is elegant, but the results are not unexpected.

Young adults with an LDL-C >100 mg/dL had a 64% increase in myocardial infarctions and coronary heart disease deaths compared with those young adults whose LDL-C was <100 mg/dL. This effect was independent of their older adult LDL-C values. Similarly, an SBP in young adulthood >130 mm Hg increased the risk of heart failure (HF) 37% compared with a SBP <120 mm Hg, and a DBP >80 mm Hg in young adulthood increased HF risk 21% compared with a DBP <80 mm Hg.

Although the results are not surprising, this article raises important clinical points. We should probably think about heart disease risk factors similarly to how we think about cancer risk based on pack-years of cigarette exposure. A patient’s duration of elevated risk factors is almost certainly a better predictor of outcomes than isolated measurements done at an older age. This highlights the importance of addressing elevated risk factors even in young adults, but this group is often under-treated or not treated at all. Young adults do not recognize the late life consequences of their risk factors, and clinicians underestimate young patients’ lifetime risk because these patients’ estimated 10-year risk is either low or cannot be calculated.

This article reminds us that the child is indeed father to the man, and that the young adult’s cardiovascular risk factors ultimately become the older adult’s cardiac disease.