Premature Coronary Disease

What makes coronary disease "premature"

Coronary artery disease usually develops over decades, and most heart attacks occur after 65. Premature disease means plaque has built up much earlier. Guidelines use a family history of premature disease, meaning a heart attack, stent, bypass or sudden cardiac death in a first-degree relative before 55 in a male or 65 in a female, as a risk-enhancing factor. Some studies define very premature disease as before 40 or 45.

Causes and risk factors

Inherited

• Familial hypercholesterolemia (FH): a genetic condition causing very high LDL cholesterol from birth. It affects about 1 in 250 people, and most are undiagnosed. Untreated, it greatly raises the risk of heart attack before 50.
• High lipoprotein(a) [Lp(a)]: an inherited cholesterol particle that promotes plaque and clotting. About 1 in 5 people has elevated levels. Diet and exercise do not lower it much.
• family history of early heart disease, which reflects shared genes and lifestyle

Modifiable

• smoking and vaping, the strongest modifiable risk factor in young people
• diabetes, including type 1 diabetes of long duration
• high blood pressure
• obesity and metabolic syndrome
• physical inactivity and unhealthy diet
• cocaine, methamphetamine and anabolic steroid use
• chronic kidney disease

Other contributors

• autoimmune and inflammatory diseases: lupus, rheumatoid arthritis, psoriasis, HIV
• pregnancy complications: preeclampsia, gestational diabetes and early menopause increase later risk in women
• South Asian ancestry, associated with earlier and more aggressive disease
• childhood cancer treatment with chest radiation

Non-atherosclerotic causes of heart attacks in young people

Some heart attacks in young adults are not from plaque: spontaneous coronary artery dissection (SCAD) in young women, coronary spasm, blood clots, and coronary aneurysms after Kawasaki disease.

Symptoms

Symptoms are the same as coronary disease at any age:

• angina: chest pressure or tightness with exertion or stress
• breathlessness, fatigue
• heart attack symptoms: chest pain, sweating, nausea, pain in the arm, jaw or back

Young people often dismiss symptoms or attribute them to anxiety or indigestion, which delays care.

Testing and diagnosis

• lipid panel: LDL cholesterol of 190 mg/dL (4.9 mmol/L) or more suggests FH
• Lp(a): guidelines increasingly recommend measuring it at least once in every adult
• blood sugar, HbA1c, blood pressure and kidney function
• coronary artery calcium (CAC) scan: shows calcified plaque and helps refine risk
• stress testing, CT coronary angiography or invasive angiography if symptoms suggest angina
• genetic testing for FH, and cascade screening of relatives once FH is identified

Prevention and treatment

• cholesterol lowering: statins are first-line; ezetimibe, PCSK9 inhibitors, inclisiran or bempedoic acid are added when needed, especially in FH
• managing Lp(a): focusing on lowering LDL and other risk factors; Lp(a)-lowering drugs are in late-stage trials
• stop smoking and vaping completely
• blood pressure and diabetes control
• heart-healthy eating (Mediterranean-style), regular exercise (at least 150 minutes a week), healthy weight
• avoid stimulant drugs
• after a heart event: stents or bypass, antiplatelet therapy, beta blockers, cardiac rehabilitation
• children of parents with FH or early heart disease should have cholesterol checked; universal screening is recommended between ages 9 and 11

Frequently asked questions

What is premature coronary artery disease?

It is coronary artery disease that develops at a younger age than usual, generally before 55 in men or 65 in women. It often reflects inherited high cholesterol, high Lp(a), smoking, diabetes or other risk factors.

What causes heart disease in young people?

Common causes are familial hypercholesterolemia, high lipoprotein(a), smoking, diabetes, high blood pressure, obesity, inflammatory diseases and stimulant drug use. Some young heart attacks are due to artery dissection or spasm rather than plaque.

Should I be tested if my parent had an early heart attack?

Yes. A family history of premature heart disease is a strong risk factor. Ask your doctor for a cholesterol panel and Lp(a) test, and a discussion of your overall risk. Children in the family may also need cholesterol screening.

Can premature coronary disease be prevented?

Often, yes. Early identification of high cholesterol or Lp(a), cholesterol-lowering medicines, stopping smoking, controlling blood pressure and diabetes, and a healthy lifestyle can greatly reduce risk, even in people with genetic risk.