Most cases of cardiovascular disease (CVD) are caused by risk factors that can be controlled, treated, or modified, such as elevated cholesterol, high blood pressure, obesity, tobacco use, lack of physical activity, and diabetes.1 A common approach used in clinical practice is to wait until risk factors develop to begin intervening with lifestyle changes or pharmacologic treatment, instead of preventing or delaying the onset of risk factors.2 Young adults (defined as ages 20–39 years in this article) are responsible for their own health behaviors that are formed early in life.3 Before their lifestyle patterns become well established, it is important to target young adults for primary prevention of CVD, which is essential for delaying the progression of CVD in later years.2,4 According to the American Heart Association (AHA) survey of 1248 adults aged 18 to 44 years, 43% of young adults indicated that they were not concerned about CVD, and one-third of young adults do not understand the connection between their current health behaviors and the risk for developing CVD in the future.5 In general, young adults in the United States are not realistic about their health and eating habits; in fact, 9 of 10 believe that they follow a healthy lifestyle, but in reality, most consume large amounts of fast food, alcohol, and sugary drinks and have lifestyles that put them at higher risk.5 This lack of insight by young adults is estimated to increase CVD deaths in this population as they age 10 to 20 years.5 Similarly, the Coronary Artery Disease Risk Development in Young Adults (CARDIA) study followed young adults between the ages of 18 and 30 years for 25 years and reported atherosclerotic changes during young adulthood that continued to have a cardiovascular health impact during middle age.2,6–8 Taken together, this information regarding development of atherosclerosis during young adulthood supports intervening during young adulthood to prevent CVD mortality in later decades.6–13
The purpose of this literature review was to examine what is known about cardiovascular risk factors (CRFs), with an emphasis on the common risk factors—hyperlipidemia (HLP) and hypertension (HTN)—in young adults. Specifically, this review will determine what guidelines are available for screening and treating CRFs in young adults and identify the gaps in the literature related to guidelines and treatment. The following research questions are being examined through this literature review:
- What CRFs in young adults contribute to increase in cardiovascular risk in the future?
- What are the current guidelines addressing young adults who have or who manifest CRFs?
- What are the current screening and treatments available to young adults who present with CRFs?
An extensive review of the medical literature from the electronic databases using MEDLINE, EBSCO, PubMed, CINAHL, Cochrane, and Google Scholar was done. Additional relevant studies were discovered within the obtained articles. The electronic search was performed by the first author from May 2012 through December 2013, to identify published studies from 2007 to 2013 (classic articles were also included) using terms such as CVD, CRFs, HLP, dyslipidemia, lipid levels, hypercholesterolemia, cholesterol, cholesterol guidelines, HTN guidelines, HTN, triglycerides, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and screening, in conjunction with the term young adults as a restriction on the search engine. The initial assessment of available published articles was aimed at the population of young adults in general, and as the search continued, the inclusion and exclusion criteria were modified and redefined. Specifically, articles that were included in the review were studies on CVD and CRFs in young adulthood (20–39 years old). A total of more than 170 articles were retrieved, with only 26 articles included. The Table includes information on each of the studies reviewed and organized by the following categories: purpose, population/design, and key findings. Themes were identified among the reviewed articles and were organized by subheadings in this article.
Literature Reviewed: Risk Factors in Young Adults
The Hard Coronary Heart Disease 10-year risk score documented that the predictors for coronary heart disease (CHD) include age, gender, total cholesterol levels, HDL-C, high blood pressure, and smoking status,31 and CHD is one type of CVD. These risk factors are found to be similar in the literature for young adults except for race/ethnicity and the addition of LDL-C, rather than just HDL-C, and total cholesterol. The primary risk factors identified in the literature for young adults are age; gender; race/ethnicity; smoking status; high blood pressure; and elevated lipid levels especially LDL-C, not HDL-C, levels. Prevention or reduction of risk factors is important because the severity of atherosclerosis increases as the number of risk factors increases.6,24
The true definition of what ages fall under young adulthood is inconsistent among the literature. In addition, the rationale of the age ranges that were being studied is not provided in research articles. According to the CARDIA study (an ongoing, leading study in young adults), young adulthood is targeted because these individuals are at the stage of life with the capability to make independent behavioral choices and establish behavior patterns that may influence lifetime cardiovascular risk; thus, they may be easier to influence than children, whose decisions rest in the hands of their guardians.4 Importantly, understanding CRFs in young adults will assist in developing the appropriate prevention strategies before lifestyle habits become well established.4 Because of the incongruent age ranges for young adults, on the basis of Erik Erikson’s stages of development,32 individuals between the ages of 19 and 40 years were classified as young adults, which is relatively close to what was used in the National Health and Nutrition Examination Survey (NHANES) (ie, ages 20–39 years). This is consistent with the Hard Coronary Heart Disease 10-year risk score, which uses an upper age limit of 39 years, because the risk for CHD increases after the age of 40 years.31
Several studies demonstrated significant gender differences in risk factors of CVD.2,3,19–22,33 In the Framingham 10-year risk score, women and men were scored separately.31 In addition, a higher prevalence of CVD is commonly found in young adult men compared with women because CVD presents approximately 10 years later in women.2,15,34 According to recent statistics provided by the AHA, the prevalence of CVD in young adults between the ages of 20 and 39 years is 14.2% for men and 9.7% for women.20,35,36 Two other studies also reported that the prevalence of CVD was higher in men compared with women.2,22,33 Furthermore, specific lipid levels such as triglycerides, LDL-C, and total cholesterol levels were higher in men compared with women,13,14,22,24 except for one article by Schober et al,37 which reported higher total cholesterol levels in women (17.3%) compared with men (13.8%). Levels of LDL-C were found to be positively associated with age, with an estimated increase of 19.0 mg/dL during 10 years for men and 2.8 mg/dL for women.3 However, Hyre et al21 reported that men have lower LDL-C level control rates compared with women. In the Minnesota Heart Study, women were found to be significantly lower in awareness, treatment, and control compared with men, 6.0% and 13.1%, respectively.19 Conversely, 3 studies reported that young women have higher screening rate than do men.24,28,29 Taken together, the data indicate that young adults, especially men, have a higher prevalence of CVD, yet the screening rate is lower in men compared with women.
Race and Ethnicity
Race and ethnicity are related to CVD, and in particular, non-Hispanic whites are more likely than African American or Hispanic individuals to have optimal cardiovascular health.3,21,28,29,33,35,36 Hispanic and African American populations had a higher prevalence of specific elevated lipid levels than did non-Hispanic whites; however, these populations were lower in screening and control rates for HLP.28,29,33 Articles resulting from the CARDIA data reported that there is a higher prevalence of elevated LDL-C in African American populations compared with non-Hispanic whites.3 According to the 2005–2008 NHANES data period, there was no difference in LDL-C levels reported between non-Hispanic white and African American men; however, Hispanic men had higher LDL-C levels compared with non-Hispanic white and African American men.35
Several studies demonstrated that smoking cigarettes is related to an increased risk for CVD.2,6,9,12,15,17,20 Huang et al17 reported that cigarette smoking in adults younger than 35 years was one of the main risk factors associated with acute myocardial infarction (MI) compared with older adults (≥65 years). Pearson et al12 studied young adults in medical school between the ages of 19 and 35 years and reported that individuals who smoked 2 packs per day had an increased risk for developing CHD in 30 years (8.6% vs 2.0% for nonsmokers). This percentage was computed using cumulative incidence curves that demonstrate the probability of developing CHD over time with different risk factor levels. In addition, Berenson et al9 reported that fatty-streak lesions in the coronary vessels were higher in young adults who were cigarette smokers versus nonsmokers. Two studies reported a positive correlation between cigarette smoking and coronary atherosclerosis in young adults.2,9 Furthermore, according to the Framingham 10-year risk score, smokers aged 20 to 39 years had a higher risk for developing coronary atherosclerosis compared with nonsmokers; specifically, women added 9 points and men added 8 points to their CHD risk score if they were smokers.15,31
High Blood Pressure
Several studies demonstrated that HTN is related to increased risk for CVD.2,6,9,12,17,20,21,23 Berenson et al9 reported that the extent of atherosclerotic lesions that cause CHD are significantly correlated (P < 0.05) to systolic blood pressure (SBP), diastolic blood pressure (DBP), total cholesterol, LDL-C, and triglycerides. Pearson et al12 reported that the probability of young adults developing HTN within 30 years of age ranged from 3% to 49%. A study by Ruixing et al23 reported significant correlations (P < 0.05) between HTN and HLP in participants with a wide range in age (15–84 years). Although there are studies examining the relationship between blood pressure and elevated lipid levels, more studies are needed to better define those young adults at high risk.
Current Guidelines for Hypertension in Young Adults
The Seventh Report of the Joint National Committee (JNC 7) are guidelines developed by the National Heart, Lung, and Blood Institute for evaluating high blood pressure.38 The JNC 7 guidelines state that young men have little understanding of high blood pressure and were the least compliant in taking their blood pressure medication. The JNC 7 guidelines also recognized the danger of the lack of blood pressure control in this population.38 Nguyen et al39 reported that the prevalence of HTN in young adults between the ages of 25 and 32 years was 19%, which was higher than the national data of 4% from NHANES during 2007 to 2008. The guidelines for high blood pressure acknowledge the problem in young adults, yet the guidelines lack direction for screening and treatment. The new release of JNC 8 in 2013 has provided recommendations for treatment of high blood pressure in young adults; however, it was reported that there were insufficient quality randomized controlled trials (RCTs) to support blood pressure recommendations in young adults.40 The JNC 8 recommends that adults younger than 30 years be treated the same as adults aged 30 to 59 years, which is to initiate pharmacologic treatment if DBP is 90 mm Hg or higher.40 The JNC 8 still lacks recommendations for screening high blood pressure in young adults in relation to CRFs.
The Johns Hopkins Precursors Study, the Bogalusa Heart Study, and the CARDIA confirmed that HLP during young adulthood is associated with CHD in later decades.6,7,9,11,12,17 The Bogalusa Heart Study examined multiple risk factors such as body mass index (BMI), blood pressure, and lipid levels from childhood to young adulthood and found that the prevalence of fatty streaks in coronary arteries increased approximately 85% from the ages of 21 to 39 years compared with 50% with children from the ages of 2 to 15 years (p = 0.01).9 Multiple articles published from CARDIA data established that HLP during young adulthood is associated with coronary artery calcification (CAC) in middle-aged adults.2,3,6–8,10 coronary artery calcification is a strong predictor of CHD that contributes to CVD in the United States.2,6,7 In addition, Loria et al2 reported that CAC accelerates between the ages of 40 and 45 years. As a result, early prevention during young adulthood to control HLP is beneficial to maintain cardiovascular health during the aging process.
The NHANES data from 1988 to 1994 and 1999 to 2002 reported a slight decline in the mean total cholesterol levels of adults 20 years or older from 206 to 203 mg/dL; and LDL-C levels, from 129 to 123 mg/dL.35 In 2003 to 2008, NHANES data showed continuing decreases in total cholesterol levels to 195 mg/dL for men and 201 mg/dL for women.35 However, the Minnesota Heart Survey done in 1980–1982 and 2000–2002 reported that the declines in total cholesterol and LDL-C levels were not consistent across all age groups. Specifically, middle-aged and older adults exhibited decreased total cholesterol levels; however, young adults had increased total cholesterol levels.14,19,35,36 Although abnormal lipid levels demonstrated decreasing trends throughout the year based on NHANES data, the percentage of individuals using lipid-lowering therapy increased as well.19,30,35,36,41 It has been reported that the use of lipid-lowering medications nearly doubled from 1999 to 2000 (8.2%), compared with 2005 to 2006 (14.0%).24,35 Overall, abnormal lipid levels are declining in the general population older than 20 years; however, in general, young adults are not improving at the same rate as middle-aged and older adults, especially if the effects of lipid-lowering therapy are also considered.
A study by Sparling et al25 involving 1088 college student volunteers between the ages of 18 and 24 years reported that 121 students (11.1%) had elevated lipid levels, and within that number, 9.1% were borderline high and 2.0% were at high risk. The young adults who had elevated lipid levels would not have known that they were at risk if they had not received the screening in one of their courses. The sample in the study was only half of the class; thus, the percentage could be doubled. This study supports the need to have lipid screening for young adults readily available, especially at universities and/or colleges.
Current Guidelines for Abnormal Lipid Levels in Young Adults
The most commonly used guidelines to evaluate abnormal lipid levels are from the National Heart, Lung, and Blood Institute and are entitled the National Cholesterol Education Program Adult Treatment Panel (NCEP ATP III). The ATP III guidelines were established by extensive review of recent clinical trials that defined issues identified by panel members and by a MEDLINE search.34 Currently, under the NCEP ATP III,34 total cholesterol, LDL-C, HDL-C, and triglycerides are 4 closely examined lipid levels obtained while a patient is fasting.
The ATP III recommends that routine lipid testing should begin at age 20 years. Three primary reasons for this recommendation were as follows: (α) early testing allows healthcare providers to identify risk factors during early stage so one can begin primary prevention, (b) young adults should be informed if they are at risk for premature CHD, and (c) lifestyle interventions are necessary for individuals with elevated cholesterol levels that are in the upper quartile for the subgroup that poses higher long-term risk.34 This recommendation is congruent with the US Preventive Service Task Force, which recommended screening for women and men to begin at age 20 years. The ATP III recommends that LDL-C levels between 100 and 190 mg/dL should be the highest priority in promoting therapeutic lifestyle change in young adults, and when LDL-C is greater than 190 mg/dL, ATP III recommends starting lipid-lowering therapy. However, there is caution because of the lack of clinical trials on the safe use of lipid-lowering medication in younger adults; more research is needed in this area.34 Additional CRFs discussed in the NCEP ATP III guidelines are cigarette smoking, blood pressure higher than 140/90 mm Hg, low HDL-C, family history of premature CHD, and age. Furthermore, the guidelines recommend using the Framingham risk score to calculate individual 10-year CHD risk.
To date, there are only 2 published trials that evaluated the NCEP ATP III guidelines in young adults.15,16 Akosah et al16 studied American men younger than 55 years and women younger than 65 years, whereas Dib et al15 specifically studied young Lebanese adults with the same age criteria as that in Akosah et al. Both studies concluded that although the ATP III guidelines covered more basis than the previous guidelines, these still underestimate the risk in young adults.
The American College of Cardiology (ACC) and the AHA released a new guideline on the assessment of cardiovascular risk and treatment of blood cholesterol to reduce atherosclerotic CVD (ASCVD) in 2013.42,43 The 2 main recommendations from the ACC/AHA guidelines are as follows: (1) use the Pooled Cohort Equations instead of the Framingham 10-year risk assessment in the NCEP ATP III because it addresses additional segments of the population that include women and African Americans42,43 and (2) assess ASCVD risk factors (instead of CHD) and estimate 10-year ASCVD every 4 to 6 years in adults aged 20 to 79 years who are free of ASCVD; specifically, long-term and lifetime risk assessment are recommended in young adults aged 20 to 39 years.42 The guidelines also point out that there are still insufficient RCT data available for young adults aged 21 to 39 years for treatment; therefore, clinician judgment should be used.42,43
Screening and Treatment
Several studies have reported an insufficient screening rate for HLP in young adults.14,24,26,28,29,37 Two of the studies reported that approximately one-third to one-half of their studied population was not aware of, or screened for, HLP.19,24 The study of Kuklina et al24 using NHANES data reported a screening rate of less than 70% with participants 20 years or older and an even lower screening rate among young adults between 20 and 39 years old, at less than 50% for women and less than 40% for men. Furthermore, on the basis of NHANES data, the screening rate has not improved significantly over time.14 The Centers for Disease Control and Prevention statistics33 related to prevalence of cholesterol screening and high blood cholesterol are consistent with NHANES data. The Centers for Disease Control and Prevention statistics reported an overall increase in high blood cholesterol screening from 72.7% to 76.0% during the 2005–2009 period; however, it was lower for young adults between the ages of 18 and 44 years (63.7%) compared with the middle-aged, 45 to 64 years (88.8%), and older adults, older than 65 years (94.7%).33 Subsequently, HLP awareness, treatment, and control rates are worse among young adults between the ages of 20 and 39 years compared with the middle-aged and older adult groups.18,27
There are multiple reasons reported in the literature explaining the possible deficiencies in screening and treatment of young adults. The primary reason proposed was that many young adults do not have a primary provider. Lau et al26 reported that those with a primary provider are more likely to receive lipid screening. Similarly, having a primary care physician was strongly associated with increased awareness of HLP and increased rates of treatment.18,44 Another possible reason reported by Yoon et al29 was that young adults lack knowledge regarding CVD risk factors. This may have resulted in less motivation for lipid screening and preventive care. Two studies looked at preventive care in young adults in general and found that they received very few preventive services.26,27 General preventive services recommended for young adults include flu vaccination, sexually transmitted diseases screening, emotional health screening, cholesterol screening, diet counseling, and exercise counseling.26 The study of Callahan and Cooper27 reported that young adult men mainly seek ambulatory health visits for acute problems instead of preventive services, and they accounted for 28% of emergency department visits. Furthermore, Callahan and Cooper27 reported that young adult women received more preventive services compared with men because women visit an obstetrician/gynecologist during childbearing years. Lastly, the lack of being insured was another issue faced by young adults. Young adults who are insured are 26% more likely to received lipid screening than those who are uninsured.26
All studies reviewed were descriptive in nature. Large data sets exist, yet there is a paucity of studies that specifically address young adults. With obesity on the rise in children,45 one could anticipate more young adults with cardiovascular risk who could benefit from early detection and screening, supporting the need for further study of young adults with CRFs, especially HLP and HTN. In addition, young adults are at the stage in life to make independent behavioral choices that may influence their long-term cardiovascular risk. Young adults have been ignored and understudied when, in fact, they are at risk for atherosclerosis leading to CHD in later decades.7–13 It is obvious that a better understanding of awareness, screening, and treatment of elevated lipid levels and high blood pressure in young adults is needed to address CVD in the young population. It is vital to understand cardiovascular risk in this population and to develop and test clinical prevention and intervention strategies to decrease the risk for developing severe CVD. Particularly, lipid and blood pressure screenings should be a priority for young adults. Future studies with scientific rigor are warranted to confirm the extent of atherosclerosis in relation to CRFs in young adults. Specifically, the ACC/AHA 2013 strongly recommends that research fill gaps in knowledge regarding short- and long-term CVD risk assessment and outcomes in all race/ethnic groups, across the age spectrum in both genders.42 Future RCTs are still needed in young adults because of the lack of RCT data available for individuals aged 21 to 39 years.43 In addition, there is a paucity of studies related to the safety and the efficacy of lipid-lowering therapies in young adults34; therefore, future clinical trials to address this gap are warranted.
Lipid screening is recommended to start in clinical practices at age 20 years; however, this is not being done in practice. Universities and community colleges would be excellent venues for more aggressive screening and follow-up of young adults. There is a need to offer lipid and blood pressure screening as a preventive service in evaluating young adults’ cardiovascular risk during the annual physical examination. Private insurance companies have been paying for preventive services during annual physical examinations for insured individuals; therefore, this should not change how the service is offered. There are advantages in screening CRFs in young adults; however, one possible argument against widespread screening might be the medical cost of doing this screening for a vast majority of healthy young adults. However, with more accurate data on incidence of risk factors in the young adult, the benefits for early prevention may outweigh the healthcare cost of future treatment. Importantly, education related to CRFs should be implemented in young adults, especially CVD prevention such as the AHA’s Life’s Simple 7: get active, eat better, lose weight, stop smoking, control cholesterol, manage blood pressure, and reduce blood sugar.46 Furthermore, emphasis should be placed on seeing a healthcare provider regularly for preventive services.
The current literature review has demonstrated the importance of attending to young adults with CRFs, especially abnormal lipid levels and high blood pressure. However, a more consistent definition of young adults and the incidence of risk factors in different age groups of young adults would better prepare us for studying the benefits and costs associated with screening young adults. The identified risk factors should be considered serious in young adults in the clinical setting and research realm because of the impact of CVD development in later decades. There are still insufficient RCT data in young adults to support the current cardiovascular risk guidelines, particularly screening and treatment in young adults with CRFs. Additional research studies addressing these issues should be encouraged and supported in young adults. Locally and nationally, we are fighting to reduce CVD prevalence, and one place to start is to begin with early screening and educating young adults with CRFs.
- Young adults have been ignored and understudied when, in fact, they are at risk for atherosclerosis leading to CHD in later decades.
- There is a need to offer lipid and blood pressure screening as a preventive service in evaluating young adults’ cardiovascular risk during the annual physical examination.
- There are still insufficient RCT data in young adults to support the current cardiovascular risk guidelines, particularly screening and treatment in young adults with CRFs.
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