Age 35 is a critical cardiovascular crossroads for your male patients.

Men develop cardiovascular disease earlier than women, reaching a 5% risk 7 years sooner, a Northwestern University study found. Risk trajectories separate around age 35.

Men tend to “have higher plaque burden at younger ages,” said Fatima Rodriguez, MD, MPH, section chief of preventive cardiology at Stanford University. “Being young is not a reason to ignore modifiable risk factors. The decisions you make at 35 are going to affect you at 45, 50, 60, and so forth.” 

Standard screenings may not tell the whole story, so ask younger male patients these questions. 

1. “When is the last time you talked to a doctor about your heart health?” 

If they don’t know, they’re probably behind on preventive care. 

“Historically, men have fewer primary care visits than women,” Rodriguez said. “For men in their early forties or late thirties, they’re often prompted by their wives or family to finally see a doctor.” For many, their first contact with healthcare is during a heart attack. They may have had modifiable risk factors but either were not screened or not educated about how to mitigate risk. 

One often ignored risk factor is high blood pressure, Rodriguez said. Some people check it at home but don’t seek help when it’s elevated, or sometimes physicians are hesitant to medicate it in younger patients. “When I see these patients later, when they're 50 or 60, it was just ignored,” she said.

2. “Has anyone in your family died young?” 

If yes, ask for the age and cause of death. (If they don’t know, see if they can text a relative to find out.) Any parent or grandparent who died of a heart problem — including sudden cardiac death, heart attack, or stroke — before 55 is a red flag, no matter how healthy your patient seems. 

“I often see people try to distinguish themselves from family members with early heart disease,” Rodriguez said. “For example, ‘They smoked, and I have a really healthy lifestyle.’” While it’s important to acknowledge your patient’s lifestyle efforts, stress that genetics matter too. 

A next step could be to check their lipoprotein a, or Lp(a), “to refine their cardiovascular risk,” said Andrew Perry, MD, a cardiovascular medicine instructor at Vanderbilt University Medical Center in Nashville. “That can be an inherited phenotype.” 

Your patient’s level of the particularly sticky form of low-density lipoprotein (LDL) cholesterol can tell you things a regular lipid panel can’t. 

“If elevated, Lp(a) is associated with increased cardiovascular risk, even in the setting of reduced and controlled LDL and HDL,” Perry said. The result could “prompt you to more aggressively control somebody's lipid panel beyond what the standard guidelines say.”

3. “What does a typical week look like in terms of physical activity?” 

Phrasing it this way is likely to yield more insight than a simple yes-or-no “Do you exercise?” 

Ideally, patients meet physical activity guidelines of 150 minutes per week of moderate-intensity movement and two muscle-strengthening sessions, but less than 1 in 3 US adults do. Adults in their mid-thirties often struggle to stay active as work and family demands increase, Perry said. If your patient can’t get to the gym, recommend realistic goals like a 10- to 30-minute walk at lunch. 

Then follow up with this question: “Have any physical activities become more challenging for you?”

“I want to know when there’s a change,” Rodriguez said. If a patient could previously run or climb hills and suddenly can’t, that may signal early coronary disease or reduced cardiac function, Rodriguez said.

4. “Do you wake up feeling rested?”

A “no” to this question could point to obstructive sleep apnea (OSA), which increases cardiovascular risk by 82%. Probe for other clues, such as waking up during the night, having trouble falling back to sleep, or the classic symptom — loud snoring noticed by their partner.

These signs may seem obvious, but patients often overlook them. Only about a third of US adults with OSA symptoms seek medical evaluation. 

If you suspect OSA, refer the patient to a sleep physician. With treatment, it's one of the easiest cardiovascular risk factors to reverse, Rodriguez said.

Rodriguez and Perry reported having no relevant disclosures.