Association of Coronary Heart Disease Risk Factors with Microscopic Qualities of Coronary Atherosclerosis in Youth (PDAY)

The Pathobiological Determinants of Atherosclerosis in Youth (PDAY) study examined coronary arteries from 760 young Americans aged 15 to 34 who died of external causes — providing a unique window into the earliest stages of atherosclerosis and its relationship to conventional risk factors.

Advanced atherosclerotic lesions (AHA grade 4–5) were found in 2.4 percent of male teenagers aged 15–19 and 20 percent of men aged 30–34. Women showed a similar but delayed trajectory. High non-HDL cholesterol (≥160 mg/dL) was the risk factor most strongly and consistently associated with advanced lesions, stenosis, and vulnerable plaque features. Obesity, smoking, hypertension, and hyperglycemia each contributed independently.

The trial’s central message is both sobering and actionable: atherosclerosis is not a disease that begins in middle age. It begins in adolescence, driven by the same risk factors that predict clinical events decades later. Long-range prevention — addressing lipid levels, blood pressure, and metabolic health in young adults, not just at middle age — is what the pathology demands.

We rate the evidence strong, with very high clinical significance. A landmark autopsy study providing irreplaceable biological evidence that coronary atherosclerosis and its conventional risk factor determinants are established well before clinical symptoms appear — fundamentally supporting the case for early, sustained cardiovascular risk management.