When should statins be prescribed for patients younger than 40 years old?

This topic will discuss when statins should be prescribed for patients under age 40 and how to evaluate cardiovascular risk in these patients.

When should statins be used in adults under age 40? ― Statins clearly improve outcomes regardless of age in patients with a prior heart attack or stroke for SECONDARY prevention or in familial hypercholesterolemia with an LDL of 190 mg/dL or higher. But for others under 40, this is a gray area (there's no evidence).

Don't jump to statins for PRIMARY prevention in low-risk patients under 40. For example, a statin isn't likely to benefit a patient with modestly elevated LDL and no other CV risks (smoking, hypertension, etc). Emphasize lifestyle changes, such as diet and exercise, instead. On the other hand, patients under 40 with multiple cardiovascular risks might benefit, and statin risks are low. For example, consider recommending a statin for diabetes patients under 40 with additional CV risks or with long-standing disease, such as type 1 diabetes for 20 years or type 2 diabetes for 10 years.

Also consider suggesting a statin for patients with a persistently high LDL, such as 160 mg/dL or above especially with a family history of premature CV disease (male under age 55, female under age 65). For patients close to age 40, consider the American Collage of Cardiology/American Heart Association CV risk estimator as a place to start a discussion, even though it's designed for those 40 to 75. Keep in mind, age is weighted heavily in the estimator, so it's less accurate in younger patients. Generally, recommend a moderate-intensity statin (atorvastatin 20 mg, etc) when started for primary prevention in patients under 40. If women of childbearing age get a statin, ensure they're on reliable contraception. Advise stopping the statin 1 or 2 months before pregnancy if possible and avoiding statins in nursing women. For further information, see note on "Pharmacology of HMG-CoA inhibitors (Statins)".

References

Grundy, S.M., Stone, and others (2018). 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol. Journal of the American College of Cardiology, [online] 73(24). Available at: http://www.onlinejacc.org/content/accj/early/2018/11/02/j.jacc.2018.11.003.full.pdf

Newman, C.B., Preiss, D., Tobert, J.A., Jacobson, T.A., Page, R.L., Goldstein, L.B., Chin, C., Tannock, L.R., Miller, M., Raghuveer, G., Duell, P.B., Brinton, E.A., Pollak, A., Braun, L.T. and Welty, F.K. (2019). Statin Safety and Associated Adverse Events: A Scientific Statement From the American Heart Association. Arteriosclerosis, Thrombosis, and Vascular Biology, 39(2). Available at: https://pubmed.ncbi.nlm.nih.gov/30580575

Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes—2019. (2018). Diabetes Care, 42(Supplement 1), pp.S103–S123. Available at: https://care.diabetesjournals.org/content/42/Supplement_1/S103