Incorporating Risk Stratification Into the Practice of Pediatric Preventive Cardiology

Abstract

Atherosclerosis in its earliest stages is associated with the same traditional cardiovascular disease (CVD) risk factors as are associated with manifest CVD events in adulthood. Clustering of risk factors is associated with exponential increases in atherosclerotic burden from a young age. Some medical conditions and risk behaviours occurring in children can either increase the likelihood of higher levels of risk factors (such as chronic kidney disease) or the presence of risk factor clustering (such as obesity and cardiometabolic syndrome) or are associated with acquired coronary artery pathology (such as Kawasaki disease). This creates a milieu for—or increases the impact of—accelerated atherosclerosis that, in turn, increases the likelihood of premature CVD. This review highlights the importance of considering the total risk factor and risk-condition profile of pediatric patients. An algorithm is provided for stratifying patients into high-, moderate-, and at-risk categories, and practical examples are provided as to how the evaluation and management of 1 risk factor or risk condition might need to be intensified in the context of additional risk factors or risk conditions. For example, for treatment of an adolescent with familial hypercholesterolemia, the target low-density lipoprotein cholesterol level might be lowered by the concomitant presence of low high-density lipoprotein cholesterol or elevated lipoprotein(a) levels. As awareness of cardiovascular risk and atherosclerosis in pediatric patients increases, new at-risk conditions that warrant consideration are emerging. The identification and management of high-risk individuals is an important part of the overall practice of pediatric preventive cardiology.

Healthy Lifestyle Intervention and Weight Loss Improve Cardiovascular Dysfunction in Children with Obesity

“…In this view, the pediatric age is a window of opportunity for improving public health. On the over hand, the evaluation of cardiovascular risk and risk stratification should become common practice during a pediatric visit for children with obesity [ 30 ].…”

The Detection, Evaluation, and Management of Dyslipidemia in Children and Adolescents: A Canadian Cardiovascular Society/Canadian Pediatric Cardiology Association Clinical Practice Update

“…10 Selective screening also applies to children with medical conditions (such as type 2 diabetes mellitus and chronic kidney disease) or risk factors for premature CVD (such as obesity, hypertension, and smoking status). 10,23 Selective screening on the basis of family history is imperfect and might miss 30%-60% of children with dyslipidemias, particularly because accurate and reliable measures of family history are frequently not available. 5,10,24 On the basis of this, the Expert Panel guidelines recommended universal screening at age 9-11 years and again between ages 17 and 21 years.…”

“…Selective screening at any time should be considered for children with identified CV risk factors or risk conditions, or a positive family history of premature CVD or dyslipidemia. Data from de Ferranti SD, et al, 36 Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents; National Heart, Lung, and Blood Institute, 10 and Khoury et al 23 Physical examination should include plotting height, weight, and body mass index on standardized growth charts, measuring blood pressure, assessing pubertal stage, excluding goiter or hepatosplenomegaly, and identifying signs of insulin resistance such as acanthosis nigricans. The presence of acanthosis nigricans should prompt a more detailed evaluation for insulin resistance and/or metabolic syndrome.…”

Measuring Cardiovascular Risk Across the Lifespan: When Should We Start Checking and What Should We Do About It?

“…Rather, they cluster and track from childhood to adulthood. 8 Rather than treating CVRFs in adulthood, our patients are better served by preventing the occurrence of the CVRFs in the first place through primordial prevention. Specifically, many CVRFs cluster within the metabolic milieu of obesity.…”