At What Age Should You Think About Assessing Your Risk For Heart Disease?

The answer here surprises most people.

There is a phrase in aviation:

“The most useless part of the runway is the runway that is behind you”.

A runway might be a mile long, but if you start your takeoff roll at the halfway mark, it doesn’t really matter that the runway is a mile long.

You now only have half a mile left to work with.

The same principle applies to assessing and managing your risk of heart disease.

I am frequently asked ‘When’ should people start thinking about assessing their risk of heart disease and also focusing on reducing it.

The answer is…. Now.

Yep. No matter what age you are.

It is now.

The answer is always now.

The Answer Will Always Be Now.

Unless, of course, you do not have any interest in reducing your risk of heart disease.

Then, the answer is never.

Knock yourself out. Enjoy the ride.

To understand why the answer is always ‘Now’, I want to highlight three key points and then point to the evidence that supports the idea that reducing risk early is always better.

Number 1.

Everyone starts with no plaque in the coronary arteries, but over a long enough time frame, everyone develops plaque in their coronary arteries.

By age 80, almost everyone will have evidence of advanced plaque in their coronary arteries, as defined by a cardiac CT¹.

What this means is that we never really ‘prevent’ heart disease.

In truth, even with our best efforts we likley only ‘delay’ it to as late as possible in life.

But the goal in this instance is to die after a long and healthy life ‘with’ coronary artery disease rather than ‘from’ coronary artery disease.

However, the chances of dying from heart disease are directly proportional to the amount of plaque in your coronary arteries.

Therefore, the key to not dying from heart disease is to have as little plaque for as long as possible or until as late as possible in life.

Number 2.

You are accumulating plaque in your arteries far earlier than you think.

Plaque accumulation happens in stages.

The calcified plaque identified on the cardiac CTs mentioned above represents later-stage advanced plaque.

Earlier stages of plaque precede this for many years but are generally not visible on any of the imaging tests we use to identify plaque.

But it is likely still there.

How early does plaque start forming?

In your 40’s, 50s, 60’s?

No.

Probably From Childhood.

We know the earliest stages of plaque accumulation are identifiable even from a very young age².

Almost 20% of teenagers have some evidence of early plaque.

By age 30 to 39, that figure rises to 60%.

There are even case reports of plaque formation in the arteries of newborns³.

So yes. Plaque is accumulating in your coronary arteries far earlier than you think.

Almost regardless of what age you are, that process has probably begun.

Number 3.

“You cannot die from a condition you do not have.”

The above statement is obviously an oversimplification, but in general terms, it is true.

The key to heart disease is to delay the onset as late as possible in life and, even when it does start to accumulate, to have as little as possible for as long as possible.

In terms of CAC score, which is a measure of the amount of plaque in your coronary arteries (and risk), the goal is twofold:

1. To convert to a CAC score >0 as late as possible in life.

2. Keep your CAC score as low as possible for as long as possible.

So now you are aware of 3 fundamental points:

1. Everyone starts with no plaque in the coronary arteries, but over a long enough time frame, everyone develops plaque in their coronary arteries.

2. You are accumulating plaque in your arteries far earlier than you think.

3. “You cannot die from a condition you do not have.”

Based on the three key points, when should you start thinking about assessing and reducing your risk of heart disease?

You got it.

Today.

The answer is always today.

But is there an advantage to starting early?

Yes.

Let me show you why.

Getting your lifestyle right is fundamental to delaying the onset of advanced plaque in your coronary arteries and going from a CAC score of 0 to above 0⁴.

If you get all of your lifestyle metrics right, the probability of delaying the onset of advanced plaque goes up considerably.

This isn't about becoming obsessed with your health.

It is simply about getting the fundamentals right.

Being active. Good nutrition. Normal weight. Not smoking. Controlling LDL cholesterol. Managing blood pressure. Avoiding insulin resistance.

Simple.

But not easy.

But absolutely worth it.

Control Risk Factors Early.

The majority of risk can be managed with close attention to lifestyle factors, but for some, medications may be needed.

But should you start them early or wait until you are older?

Have a look at this data and then you decide.

Let's take a 42-year-old male with an LDL cholesterol of 5.1 mmol/l (197 mg/dl) with normal blood pressure who is a little overweight, does not smoke or have diabetes and has a family history of heart disease.

Not an uncommon scenario.

Let’s assume they have really tried from a lifestyle perspective and are not making any more progress.

Again. Not an uncommon scenario.

How much would they benefit from going on a cholesterol lowering medication?

Over the next 10 years?

Not very much. Probably less than a 1% reduction in risk.

But what about until age 80?

A MUCH bigger reduction in risk.

Now add in an elevated Lp(a), which is a common genetic cholesterol particle disorder, and that risk reduction gets even bigger.

Suddenly, a 43% chance of a heart attack or stroke becomes a 19% risk.

That is a big reduction in risk.

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This same principle applies to pretty much every other risk factor also, not just LDL cholesterol.

The goal is the same.

Get it right early.

For longer.

To maximise risk reduction over your lifetime.

Waiting is not a very sensible strategy if your goal is maximally reducing cardiovascular risk.

Let’s see how it plays out with the impact of getting type 2 diabetes later rather than earlier in life.

Type 2 diabetes is largely avoidable early in life with close attention to lifestyle factors.

A diagnosis of type 2 diabetes in your 30s because of poor lifestyle factors can mean a loss of 14 to 16 years of life expectancy⁵.

As a percentage of your life, that is a huge amount.

But what happens if you delay the onset of type 2 diabetes to much later in life?

It still stands to shorten your life.

But much less so.

A diagnosis in your 70’s versus your 30’s can mean a 2-year reduction in life expectancy.

Not good, but a whole lot better than a 16-year reduction.

I could keep giving examples for lots of other risk factors and highlighting that earlier intervention is better but I think you get the point.

So, when should you start thinking about assessing and addressing cardiovascular risk factors?

I think you know the answer by now.

It’s today.

The answer is always today.

In Case You Missed Them:

1. Coronary artery calcium for the prediction of mortality in young adults <45 years old and elderly adults >75 years old. Eur Heart J. 2012 Dec;33(23):2955-62.

2. High prevalence of coronary atherosclerosis in asymptomatic teenagers and young adults: evidence from intravascular ultrasound. Circulation. 2001 Jun 5;103(22):2705-10.

3. Perinatal and infant early atherosclerotic coronary lesions. Can J Cardiol. 2008 Feb;24(2):137-41.

4. Life's Simple 7 Cardiovascular Health Metrics and Progression of Coronary Artery Calcium in a Low-Risk Population. Arterioscler Thromb Vasc Biol. 2019 Apr;39(4):826-833.

5. Emerging Risk Factors Collaboration. Life expectancy associated with different ages at diagnosis of type 2 diabetes in high-income countries: 23 million person-years of observation. Lancet Diabetes Endocrinol. 2023 Oct;11(10):731-742.