PEDIATRICS Vol. 119 No. 3 March 2007, pp. 618-621 (doi:10.1542/peds.2006-3557)

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ENDORSED POLICY STATEMENT

Cardiovascular Risk Reduction in High-Risk Pediatric Populations

Executive Summary of an American Heart Association Scientific Statement: Cardiovascular Risk Reduction in High-Risk Pediatric Patients

While atherosclerosis has been clearly shown to begin in childhood, the process is usually subclinical, the rate of progression is slow, and the appropriate therapeutic approach is preventive. By contrast, certain pediatric disease states are associated with dramatically accelerated atherosclerosis, with clinical coronary events occurring in childhood or very early adult life. Intensive cardiovascular risk reduction is of critical importance in such children. This executive summary summarizes the work of an expert panel convened by the American Heart Association to develop recommendations for cardiovascular risk management in high-risk pediatric settings. The recommendations were peer reviewed and then endorsed by the American Academy of Pediatrics; the complete scientific statement was published in the December 12, 2006, issue of Circulation (2006;114:2710–2738).

In pediatric populations, a large and growing knowledge base documents the presence of accelerated atherosclerosis, the relationship of the atherosclerotic process to the number and intensity of defined risk factors, and the response at the clinical, pathologic, and vascular level to risk factor change. The panel reviewed all the available science regarding very early atherosclerotic disease as well as the range of approaches to risk assessment and treatment and the response to intervention. From this evidence, 8 pediatric disease settings were selected for inclusion: (1) familial hypercholesterolemia; (2) diabetes mellitus, type 1 and type 2; (3) chronic kidney disease; (4) post–heart transplantation; (5) Kawasaki disease; (6) chronic inflammatory disease; (7) congenital heart disease; and (8) childhood cancer survivors. Based on the presence of manifest atherosclerotic disease in childhood, a stratification protocol was developed, and each disease was classified (Table 1):

Tier II. Pathophysiologic evidence for arterial dysfunction indicative of accelerated atherosclerosis before 30 years of age;

Tier III. Increased cardiovascular risk factors with epidemiologic evidence for coronary disease early in adult life but after 30 years of age.

Recommendations for cardiovascular risk management for each tier were tailored to the specific disease setting and adjusted for risk intensity. For children at the highest risk (tier I), the intervention strategy regards the diagnosis as a "coronary heart disease equivalent" with recommendations for risk reduction similar to secondary prevention guidelines for adults with established coronary disease. For tier II, complete risk factor assessment is recommended with specific defined therapeutic goals. For children with diagnoses in tier III, the focus is on complete risk factor assessment with therapeutic goals as defined for children in general.

Recommendations for evaluation and treatment are summarized in a treatment algorithm (Fig 1) and in 2 supporting tables (Tables 2 and 3). For review of the evidence for early coronary disease and the response to intervention as well as supporting references, readers are referred to the complete scientific statement.

View larger version (52K): [in this window] [in a new window]   FIGURE 1 Directions: Step 1: risk stratification by disease process (Table 1). Step 2: assess all cardiovascular risk factors. If there are 2 comorbidities, assign patient to the next higher risk tier for subsequent management. Step 3: tier-specific intervention cut points/treatment goals defined. Step 4: initial therapy: for tier I, initial management is therapeutic lifestyle change (Table 2) plus disease-specific management (Table 3). For tiers II and III, initial management is therapeutic lifestyle change (Table 2). Step 5: for tiers II and III, if goals are not met after initial management, consider medication as outlined in Table 2. FH indicates familial hypercholesterolemia; ESRD, end-stage renal disease; CV, cardiovascular; CAD, coronary artery disease; %ile, percentile; BP, blood pressure; LDL, low-density lipoprotein; FG, fasting glucose; HgbA1c, hemoglobin A1C; ht, height; pt, patient; TLC, therapeutic lifestyle change.

The recommendations presented here are directed toward the primary care providers and pediatric subspecialists who care for these patients in childhood as well as to the internists, family practitioners, and adult subspecialists who will assume their care when they reach adult life. As new information develops, the guidelines will need to be modified to improve guidance on cardiovascular risk reduction in such high-risk pediatric settings. Finally, decisions on the management of individual patients must be tailored to their unique circumstances.

FOOTNOTES

All statements of endorsement from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

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