Risk stratification for children and adolescents at risk for early cardiovascular disease

High-risk conditions and risk factors	Moderate-risk conditions and risk factors	At-risk conditions and risk factors
Homozygous FH Diabetes mellitus (type 1 or 2) End-stage kidney disease Kawasaki disease with persistent coronary aneurysms Solid-organ transplant vasculopathy Childhood cancer survivor following stem cell transplantation Multiple comorbidities – Any moderate-risk condition plus ≥2 additional moderate- or at-risk factors	Severe obesity (BMI ≥99^th percentile or ≥35 kg/m²) Confirmed hypertension (BP >95^th percentile or ≥130/80 mmHg on 3 separate occasions) Heterozygous FH Predialysis chronic kidney disease Aortic stenosis or coarctation Childhood cancer survivor with exposure to chest irradiation Multiple risk factors – ≥3 at-risk conditions or risk factors	Obesity that is not severe (BMI ≥95^th to <99^th percentile) Insulin resistance with comorbidities (eg, NAFLD, PCOS) Family history of premature CVD* Parent with known dyslipidemia (eg, FH) or TC >240 mg/dL (6.2 mmol/L) Current smoker or significant exposure to second-hand smoke White-coat hypertension (elevated BP measurements in the office with normal values outside the office setting) Chronic inflammatory disease (eg, SLE, systemic JIA) HIV infection Kawasaki disease with regressed coronary aneurysms Cardiomyopathy (eg, HCM) Surgically repaired congenital heart disease involving coronary artery translocation (eg, TGA repair) Childhood cancer survivor with cardiotoxic chemotherapy only Adolescent depressive and bipolar disorders

FH: familial hypercholesterolemia; BMI: body mass index; BP: blood pressure; NAFLD: nonalcoholic fatty liver disease; PCOS: polycystic ovary syndrome; CVD: cardiovascular disease; TC: total cholesterol; SLE: systemic lupus erythematosus; JIA: juvenile idiopathic arthritis; HCM: hypertrophic cardiomyopathy; TGA: transposition of the great arteries.
* Family history of premature CVD is generally defined as heart attack, treated angina, interventions for coronary artery disease, sudden cardiac death, or ischemic stroke in a first-degree relative (parent or sibling) before age 55 (males) or 65 (females).

Adapted from:

Daniels SR, Benuck I, Christakis DA, et al. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: Full report, 2011. National Heart Lung and Blood Institute. Available at: http://www.nhlbi.nih.gov/guidelines/cvd_ped/peds_guidelines_full.pdf (Accessed on July 11, 2019).
de Ferranti SD, Steinberger J, Ameduri R, et al. Cardiovascular risk reduction in high-risk pediatric patients: A scientific statement from the American Heart Association. Circulation 2019; 139:e603.

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Risk stratification for children and adolescents at risk for early cardiovascular disease