Why are more young people having heart attacks?

Heart attacks have traditionally been thought of as a concern for older adults, not something that people under the age of 50 would tend to worry about. But growing research shows quite the opposite. While heart attack rates are declining in older populations, they’re rising among younger adults — those in their 30s, and even their 20s. 

It’s not just heart attacks; heart-related diseases overall are becoming much more prevalent in young adults compared to decades past. Studies have found that cardiovascular-related hospitalizations have significantly increased among adults under 45, and that nearly half of all heart attack patients in recent years were 54 years old or younger.

Dr. Ron Blankstein, a preventative cardiology specialist at Brigham and Women’s Hospital and professor at Harvard Medical School, joined GBH’s All Things Considered host Arun Rath to help make sense of what’s behind this shift. What follows is a lightly edited transcript.

Arun Rath: I talked about that common perception about heart attacks, and that’s really, apparently, out of date right now. Tell us about what’s been causing this overall trend and why this is happening with younger people, even as rates among older populations are going down.

Dr. Ron Blankstein: That’s exactly right. What we have seen nationally is the statistic that even though, due to a lot of our efforts, the rate of heart attacks has gone down, the proportion of heart attacks in young individuals has actually increased over time.

My group has been very motivated by that statistic to try to figure out why that is. Some of this is actually driven by factors that I think we all know have been happening, like an increase in obesity and the rate of diabetes in our country, and we see an even greater increase in young people.

Some of it is other risk factors that, at least in the cardiology community, we know these are risk factors, but young individuals don’t always appreciate that — so, things ranging from an increased prevalence of diabetes, more smoking, more hypertension or elevated blood pressure, and also use of substances such as marijuana and cocaine, which are more common in young individuals.

Rath: When we’re talking about those risk factors — like high blood pressure, diabetes, obesity — does this mean that we’re seeing these in younger people as well?

Blankstein: That’s right. These are specifically risk factors that we’re seeing commonly when young individuals have a heart attack, and I think one of the really important points is that these heart attacks are not happening out of the blue. Even though young individuals often believe that they were the picture of health until they had a heart attack, what we found is that 90% of the time, when young individuals experience a heart attack, they actually have risk factors.

Perhaps they didn’t recognize the risk factors, perhaps they were kind of dismissing them. But I think it’s a very important point that most people who experience a heart attack at a young age have underlying risk factors.

Rath: Talk a little bit about the decline in older populations. Is that a case of effective intervention over time — a better understanding of heart disease?

Blankstein: I think it is. We’ve had many advances in cardiology. Some of the important ones have been treatments, for example: lowering cholesterol with medications such as statins is something that we do a lot more now. Lowering blood pressure is also something that, even though there’s a lot of room for improvement, we have more and more guidelines on how to implement treatments. So, overall, we do see a reduction in events.

Rath: As you’re looking towards younger populations, does it involve using that same sort of toolkit? Or, what’s the approach you’re taking?

Blankstein: First of all, I think it’s really remarkable that in young individuals, when we look at the risk factors, the single most common risk factor is smoking. Half of the individuals who have a heart attack at a young age actually use cigarettes, so that’s the most common risk factor.

But then there are other [risk factors], and the approach for us is really to try to screen and identify these risk factors in young individuals, ideally before they have events. As a preventive cardiologist, my goal is often to prevent people from having heart attacks. Of course, we see people after their events, but if we want to prevent those events, we’ll want to identify all risk factors, including all risk factors that clinicians often look for, things like diabetes and elevated blood pressure.

Sometimes, there are other risk factors. Elevated cholesterol can take on various forms. So, for example, when your LDL — or bad cholesterol — is in a good range, sometimes there are other risk factors: like a low HDL cholesterol or an elevated lipoprotein (a), which is another type of lipid particle. So, there are various things that we will want to look for.

Rath: I’ve got to say, I’m a little bit surprised to hear about the prevalence of smoking. I thought it was so much on the decline. Is smoking on the rise among young people?

Blankstein: Well, the key is — it is on the decline. But if we selectively look at individuals who actually experience a heart attack at a young age, that’s where we’re seeing that rate of 50% [smoking].

So it’s kind of a mathematical issue that we’re really only looking at the numerator — the people who are actually experiencing the events — and among them, it turns out that half of them are smokers.

Rath: Are there other risk factors, aside from smoking and what you’ve already mentioned, that younger people should be thinking about so that they aren’t blindsided when heart trouble comes around?

Blankstein: I think knowing your family history is important. Some individuals who experience an event at a young age sometimes have a lot of risk factors that are well-controlled, but they have a strong family history, so it’s important not to ignore that. The use of cocaine and marijuana is also important. I think, especially, marijuana; many folks think it’s benign, but it’s probably not quite as benign as we think. And then, being overweight, being inactive, having elevated blood pressure — all important risk factors.

But one of the points that I think is really important — one of the points that I think is really important and one of the reasons why I focus on risk factors throughout our conversation — is the fact that in our guidelines in the US, we often use different risk scores to tell us who’s at increased risk.

For example, we calculate the likelihood of an individual having a heart attack over the next 10 years. These risk scores are heavily weighted by age, so if you’re young, your risk is going to be low, and if you’re old, your risk is going to be higher.

What we find is that in young individuals — at least those who experience events — if we were to go back and look at the risk scores, they actually end up being classified as low risk. When it comes to young individuals, we don’t want folks to be reassured because [of] a risk score. ... If they have risk factors, it’s important to pay attention to those, and it’s important to treat those.

Rath: That’s fascinating that with the [risk factors] we tend to hear about when we get older, you’re saying that people need to have maybe a different sense of risk assessment in general from an earlier age.

Blankstein: I think that’s right. Heart disease starts really early on in life — often decades before individuals recognize it, certainly decades before there are symptoms or events. It’s really never too early to start paying attention to these risk factors.

Most of us, when we’re young, we think we’re invincible — so we generally don’t pay attention to these things. As people grow older, they probably pay more and more attention. But I think if there’s an important message here, it’s to start paying attention to these things earlier on in life.

Rath: With identifying risk being so important, are there ways in which we’re improving ways to assess risk when it comes to disease in younger people — or everyone?

Blankstein: One of the tools that’s really been helpful for us is the use of imaging, specifically CT scans of the heart, to identify plaque earlier in life. What we sometimes can see is individuals who have plaque — plaque, of course, would not cause any symptoms. But when we find individuals who have plaque at a young age, we then want to treat them much more aggressively, both with lifestyle interventions as well as medications.

One of the common tests, which is now endorsed by several of our guidelines, is a test known as a coronary artery calcium scan. It’s a fairly simple test — you don’t need an IV, there’s no contrast involved, it takes about a second or two.

And what it does is it takes a CT picture of the heart, and when individuals have plaque in the arteries of the heart, part of that plaque can calcify or become hard, and that is easy to see on a CT.

What we then do is we calculate a score — it’s a calcium score of the arteries of the heart. The higher the score, the higher their risk of having a heart-related issue. So, one of the things that we are now using, especially when there are individuals who may have risk factors or perhaps have uncertainty about their risk, is to do a scan like this and to identify if they have plaque and, if so, how much plaque.