Introduction: Cholesterol screening and treatment in adolescents and young adults (AYAs) may improve cardiovascular disease (CVD) outcomes from lifelong high cholesterol as seen in familial hypercholesterolemia (FH), but supporting evidence is sparse.
Hypothesis: Compared to adult guidelines, pediatric cholesterol guideline strategies will lead to more treatments and decreased CVD mortality.
Methods: Using NHANES LDL and risk factors, CDC cause-specific mortality, and existing literature we constructed a Markov model to compare the effectiveness of pediatric versus adult cholesterol guidelines on the life expectancy of the US population of 20.4 million 20-year olds, including individuals with FH (defined as LDL ≥190 mg/dL).
Results: Compared with the average 20-year old life expectancy of 58.2 years, our model projected an average life expectancy of 55.7 years for an individual with undiagnosed FH. Screening and detecting an LDL≥190 mg/dL followed by statin and lifestyle treatment would increase FH AYA life expectancy by 2.1 years using Simon-Broome estimates, or 1.3-2.5 years using cause-specific or all-cause mortality reductions from the 2005 Lancet CTT statin meta-analysis. For FH prevalences ranging from 0.29% to 0.5%, the pediatric guidelines yielded a 4.0 to 5.0-day extension of life expectancy versus the adult guidelines, which for 20.4 million young adults would result in 225,000 to 278,000 additional years of life versus the adult guidelines, or 473,000 to 547,000 additional years when compared to no screening. Both guidelines detected and treated the 0.29% of 17-21 year olds with FH and had minimal effect on the 87% of individuals with an LDL <130 mg/dL. The primary benefit of the pediatric guidelines occurred in the groups with LDL 130-189 mg/dL, with 1.3 million additional years seen in the 2.6% with LDL 160-189 mg/dL and 390,000 additional years seen in the 10% with LDL 130-159 mg/dL.
Conclusions: Simulation modeling estimated the pediatric vs. adult cholesterol guidelines would lead to more diagnoses and treatment, thereby lowering LDL and increasing survival; benefits accrued primarily in AYAs with LDL 160-189 mg/dL. Further studies are needed to confirm the benefit of AYA cholesterol screening and treatment on life expectancy.