ﺑﺎﺯﮔﺸﺖ ﺑﻪ ﺻﻔﺤﻪ ﻗﺒﻠﯽ
خرید پکیج
تعداد آیتم قابل مشاهده باقیمانده : 3 مورد
نسخه الکترونیک
medimedia.ir

Overview of the management of the child or adolescent at risk for atherosclerosis

Overview of the management of the child or adolescent at risk for atherosclerosis
Literature review current through: Jan 2024.
This topic last updated: Oct 18, 2023.

INTRODUCTION — Atherosclerotic vascular changes can begin in early childhood, setting the stage for atherosclerotic cardiovascular disease (ASCVD) events in adulthood. For most children, atherosclerotic vascular changes can be minimized or even prevented with adherence to a healthy lifestyle. However, in some children, the atherosclerotic process is accelerated because of the presence of identifiable risk factors (table 1). The early identification of children and adolescents with these risk factors allows for timely interventions targeting modifiable risk factors to slow the atherosclerotic process and thereby potentially prevent or delay ASCVD.

An overview of the management of the child or adolescent at risk for atherosclerosis will be presented here. Related topics include:

(See "Pediatric prevention of adult cardiovascular disease: Promoting a healthy lifestyle and identifying at-risk children".)

(See "Overview of risk factors for development of atherosclerosis and early cardiovascular disease in childhood".)

(See "Dyslipidemia in children and adolescents: Definition, screening, and diagnosis".)

(See "Dyslipidemia in children and adolescents: Management".)

(See "Familial hypercholesterolemia in children".)

RATIONALE FOR INTERVENTION — Large, prospective, population-based, randomized controlled trial studies in adults demonstrate that reducing risk factors associated with atherosclerotic cardiovascular disease (ASCVD) decreases the occurrence of future ASCVD events. (See "Overview of established risk factors for cardiovascular disease", section on 'Established risk factors for atherosclerotic CVD'.)

Similar long-term outcome data based on randomized clinical trials are not available for the pediatric population. However, prospective observational studies link the development of early-onset ASCVD risk factors to premature atherosclerotic changes in children. Furthermore, ASCVD risk factors track from childhood to adulthood. (See "Overview of risk factors for development of atherosclerosis and early cardiovascular disease in childhood", section on 'Atherosclerotic changes in childhood'.)

Short-term randomized controlled trials in children have demonstrated that lifestyle interventions and pharmacotherapy can successfully impact ASCVD risk factors (eg, dyslipidemia) in high-risk pediatric populations. These data are discussed separately. (See "Dyslipidemia in children and adolescents: Management", section on 'Dietary modification' and "Dyslipidemia in children and adolescents: Management", section on 'Statin therapy' and "Familial hypercholesterolemia in children", section on 'Benefits of statin therapy'.)

Based on the evidence from adult studies and the limited pediatric data, it is reasonable to assume that timely interventions to decrease or eliminate ASCVD risk factors during childhood can potentially slow the atherosclerotic process and thereby prevent or delay the onset of ASCVD [1-4].

MANAGEMENT OF INDIVIDUAL RISK FACTORS

Modifiable risk factors and health behaviors – Modifiable ASCVD risk factors and health behaviors that may present during childhood and adolescence include the following (table 1) [3,4]:

Dyslipidemia (see 'Dyslipidemia' below)

Hypertension (see 'Hypertension' below)

Insulin resistance and diabetes mellitus (see 'Insulin resistance and diabetes mellitus' below)

Obesity (see 'Obesity' below)

Smoking cigarettes and other nicotine exposures (see 'Smoking and nicotine exposure' below)

Physical inactivity (see 'Activity and inactivity' below)

Disordered sleep (see 'Healthy sleep habits' below)

Other conditions – In addition to the health behaviors and traditional ASCVD risk factors listed above, other specific conditions are associated with accelerated atherosclerosis and premature ASCVD. These conditions are summarized in the table and are discussed in greater detail separately (table 1) [3,4]. (See "Overview of risk factors for development of atherosclerosis and early cardiovascular disease in childhood", section on 'Other conditions'.):

For children with one of these conditions, heightened awareness and evaluation for concurrent ASCVD risk factors are warranted. Similar to adults, in whom multiple risk factors are considered in the evaluation of risk for ASCVD, each of the additional risk factors described below are considered when making treatment decisions (algorithm 1).

Management of these patients should include treatment of both the underlying primary disease and any comorbid ASCVD risk factors. The decision to initiate treatment and the type of intervention depend upon the individual’s risk of ASCVD risk, based upon their underlying disease and whether they have comorbid conditions (eg, hypertension, dyslipidemia, obesity). (See "Overview of risk factors for development of atherosclerosis and early cardiovascular disease in childhood".)

Dyslipidemia — Dyslipidemias are disorders of lipoprotein metabolism defined by abnormalities in the lipid profile (table 2) [4]. The rationale for initiating therapy to control lipid disorders in children and adolescents is based upon increasing evidence that pediatric dyslipidemia (particularly elevated low-density lipoprotein cholesterol) contributes to early development of ASCVD.

Lipid screening in children (algorithm 2A-B) and the management of pediatric dyslipidemias (algorithm 3) are discussed in detail separately. (See "Dyslipidemia in children and adolescents: Definition, screening, and diagnosis" and "Dyslipidemia in children and adolescents: Management".)

Hypertension — Hypertension in children is defined based on the normative distribution of blood pressure (BP) in healthy children (table 3 and table 4 and table 5). The diagnosis of hypertension is based on repeated BP measurements separated over time. (See "Definition and diagnosis of hypertension in children and adolescents".)

Treatment for hypertension includes both nonpharmacologic and pharmacologic interventions. Management decisions are dependent upon the severity of hypertension, underlying cause, evidence of end-organ damage, and other ASCVD risk factors [5].

Although there is no direct evidence that initiating therapy to lower BP in children and adolescents with hypertension lowers the risk of subsequent ASCVD [5,6], indirect data suggest that hypertension in childhood and adolescence contributes to premature ASCVD [7-9].

The treatment of hypertension in children and adolescents is discussed in greater detail separately. (See "Nonemergent treatment of hypertension in children and adolescents".)

Insulin resistance and diabetes mellitus — Insulin resistance, hyperinsulinemia, and elevated blood glucose are associated with atherosclerotic cardiovascular disease (ASCVD). In addition, children with diabetes mellitus are at increased risk for other atherogenic risk factors such as hypertension and dyslipidemia.

Randomized trials in adults and adolescents with type 1 diabetes mellitus have established that poor glycemic control contributes to long-term vascular sequelae. In addition, adult and adolescent clinical trials demonstrate that intensive insulin therapy, resulting in hemoglobin A1c levels <7, decreases the risk of ASCVD. As a result, intensive glycemic control is recommended for children and adolescents with type 1 diabetes with age-specific goals for hemoglobin A1c levels. Similar recommendations are made for children with type 2 diabetes mellitus, particularly as these children are more commonly overweight, and some believe their ASCVD risk may be higher. (See "Overview of the management of type 1 diabetes mellitus in children and adolescents" and "Complications and screening in children and adolescents with type 1 diabetes mellitus" and "Management of type 2 diabetes mellitus in children and adolescents".)

Children with type 1 or type 2 diabetes should undergo regular screening for dyslipidemia and should have BP measured at each medical encounter [4,5,10]. (See "Complications and screening in children and adolescents with type 1 diabetes mellitus" and "Chronic complications and screening in children and adolescents with type 2 diabetes mellitus".)

Obesity — Obesity, particularly central adiposity, is associated with accelerated atherosclerosis in childhood and increased risk of ASCVD in adulthood. Treatment for obesity in childhood can be challenging and it involves lifestyle changes at many levels. A multidisciplinary approach is encouraged, involving nutritional modification, behavioral counseling, and increased physical activity. The targeted body mass index (BMI) is ideally less than the 85th percentile for age and sex. These issues are addressed in separate topic reviews. (See "Prevention and management of childhood obesity in the primary care setting" and "Clinical evaluation of the child or adolescent with obesity" and "Overview of the health consequences of obesity in children and adolescents".)

Smoking and nicotine exposure — Because smoke exposure, including secondhand smoke, increases the risk of ASCVD, all patients and their close contacts who smoke should be counseled to quit smoking. A number of approaches, including behavioral therapy, nicotine replacement therapy, and other pharmacologic therapies, are available. These issues are discussed separately. (See "Management of smoking and vaping cessation in adolescents" and "Behavioral approaches to smoking cessation" and "Secondhand smoke exposure: Effects in children" and "Control of secondhand smoke exposure", section on 'Pediatrics' and "Overview of smoking cessation management in adults".)

Activity and inactivity — Evidence from both adult and pediatric studies demonstrates that daily vigorous activity and reduction in sedentary behavior improves cardiovascular health and decreases the risk of ASCVD in adulthood. The American Academy of Pediatrics and the National Heart, Lung, and Blood Institute expert panels recommend age-based daily activity for all children as summarized in the table (table 6) [4]. (See "Pediatric prevention of adult cardiovascular disease: Promoting a healthy lifestyle and identifying at-risk children", section on 'Physical activity'.)

In children with low levels of physical activity, we generally start at a lower intensity and frequency, moving to the ultimate goal of at least 60 minutes of moderate to vigorous physical activity for at least five days a week. The exercise regimen is increased gradually week by week to avoid setting unattainable goals. Directions on the expected exercise goals should be specific and clear to both the patient and parents/caregivers.

We also suggest limiting inactivity in the form of recreational screen time (eg, computer, video games, television) to ≤2 hours per day.

Physical activity and cardiovascular health in children and adults are discussed separately. (See "Pediatric prevention of adult cardiovascular disease: Promoting a healthy lifestyle and identifying at-risk children", section on 'Physical activity' and "Exercise and fitness in the prevention of atherosclerotic cardiovascular disease".)

Healthy sleep habits — In adults, abnormal sleep duration (both too little and too much) and sleep disordered breathing (eg, obstructive sleep apnea) have been linked to increased risk of ASCVD. These associations are discussed elsewhere. (See "Insufficient sleep: Definition, epidemiology, and adverse outcomes", section on 'Cardiovascular morbidity' and "Obstructive sleep apnea and cardiovascular disease in adults".)

There are fewer data establishing a link between sleep problems in childhood and risk of premature ASCVD. Nevertheless, we emphasize the importance of establishing healthy sleep habits (table 7A-B), including appropriate duration of sleep (figure 1), as part of a heart-healthy lifestyle. (See "Assessment of sleep disorders in children".)

OVERALL APPROACH TO MANAGEMENT — Management decisions for children and adolescents with risk factors for premature atherosclerotic cardiovascular disease (ASCVD) depend upon the nature of the risk factor(s), the clinical setting, and the values and preference of patients and their families/caregivers. Ideally, decisions to initiate therapy to reduce ASCVD risk would be based upon the child’s estimated risk. Although risk calculators are available to estimate 10-year ASCVD risk for adult patients, similar tools are not available for children.

Thus, the decision to intervene in children is largely dependent on the number and nature of ASCVD risk factors.

Our management approach is as follows and is consistent with published guidelines (algorithm 1) [4,5]. Therapy includes the following nonpharmacologic and pharmacologic interventions.

Counseling for weight reduction in patients who are overweight or obese, including counseling on dietary changes and physical activity. (See "Prevention and management of childhood obesity in the primary care setting".)

Promoting a heart-healthy diet rich in vegetables, fruits, and whole grains; low in saturated fat; and devoid of trans fats (table 8). (See "Dietary recommendations for toddlers and preschool and school-age children".)

Counseling to foster increased activity to an ultimate goal of at least 60 minutes of moderate to vigorous physical activity for most days of the week and limiting screen time (eg, computer and television) to less than two hours a day (table 6). (See 'Activity and inactivity' above.)

Counseling for smoking cessation for patients or household members who smoke, prevention of secondhand smoke exposure, and avoidance of initiation of nicotine use. (See "Management of smoking and vaping cessation in adolescents" and "Control of secondhand smoke exposure", section on 'Pediatrics'.)

Screening for dyslipidemia (algorithm 2A-B), and initiating treatment, if appropriate (algorithm 3). (See "Dyslipidemia in children and adolescents: Definition, screening, and diagnosis" and "Dyslipidemia in children and adolescents: Management".)

Screening for hypertension and initiating treatment, if appropriate. (See "Definition and diagnosis of hypertension in children and adolescents" and "Nonemergent treatment of hypertension in children and adolescents".)

For patients with type 1 or type 2 diabetes mellitus, targeting age-appropriate goals for hemoglobin A1c levels (<7 percent in most cases). (See "Overview of the management of type 1 diabetes mellitus in children and adolescents" and "Management of type 2 diabetes mellitus in children and adolescents".)

In patients with other underlying conditions that are associated with an increased risk of ASCVD (table 1), treatment of the primary disease. (See "Overview of risk factors for development of atherosclerosis and early cardiovascular disease in childhood", section on 'Other conditions'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Lipid disorders and atherosclerosis in children".)

SUMMARY AND RECOMMENDATIONS

Rationale – The rationale for treating children who are at risk for atherosclerosis is to delay the onset of the atherosclerotic process and, by extension, prevent or delay onset of atherosclerotic cardiovascular disease (ASCVD) in adult. This practice is based on evidence from large adult studies and more limited pediatric data that demonstrate an association between premature atherosclerosis and modifiable ASCVD risk factors. (See 'Rationale for intervention' above and "Overview of risk factors for development of atherosclerosis and early cardiovascular disease in childhood".)

Risk factors for ASCVD – Modifiable ASCVD risk factors and health behaviors that may present during childhood and adolescence include the following (table 1):

Dyslipidemia (see 'Dyslipidemia' above)

Hypertension (see 'Hypertension' above)

Insulin resistance and diabetes mellitus (see 'Insulin resistance and diabetes mellitus' above)

Obesity (see 'Obesity' above)

Smoking cigarettes and other nicotine exposures (see 'Smoking and nicotine exposure' above)

Physical inactivity (see 'Activity and inactivity' above)

Disordered sleep (see 'Healthy sleep habits' above)

In addition, other specific conditions are associated with accelerated atherosclerosis and premature ASCVD. These conditions are summarized in the table and are discussed in greater detail separately (table 1). (See "Overview of risk factors for development of atherosclerosis and early cardiovascular disease in childhood", section on 'Other conditions'.)

General management approach – Our management approach for children and adolescents with risk factors for premature ASCVD includes all of the following components (algorithm 1), which are discussed in detail separately (see 'Overall approach to management' above):

Counseling for weight reduction in patients with obesity, including dietary changes and increased physical activity. (See "Prevention and management of childhood obesity in the primary care setting".)

Promoting a heart-healthy diet rich in vegetables, fruits, and whole grains; low in saturated fat; and devoid of trans fats (table 8). (See "Dietary recommendations for toddlers and preschool and school-age children".)

Counseling to increase physical activity (table 6). (See "Pediatric prevention of adult cardiovascular disease: Promoting a healthy lifestyle and identifying at-risk children", section on 'Physical activity' and "Exercise and fitness in the prevention of atherosclerotic cardiovascular disease".)

Counseling for smoking cessation for patients or household members who smoke, prevention of secondhand smoke exposure, and avoidance of initiation of nicotine use. (See "Management of smoking and vaping cessation in adolescents" and "Control of secondhand smoke exposure", section on 'Pediatrics'.)

Screening for dyslipidemia (algorithm 2A-B), and initiating treatment, if appropriate (algorithm 3). (See "Dyslipidemia in children and adolescents: Definition, screening, and diagnosis" and "Dyslipidemia in children and adolescents: Management".)

Screening for hypertension and initiating treatment, if appropriate. (See "Definition and diagnosis of hypertension in children and adolescents" and "Nonemergent treatment of hypertension in children and adolescents".)

For patients with type 1 or type 2 diabetes mellitus, targeting age-appropriate goals for hemoglobin A1c levels (<7 percent in most cases). (See "Overview of the management of type 1 diabetes mellitus in children and adolescents" and "Management of type 2 diabetes mellitus in children and adolescents".)

In patients with other underlying conditions that are associated with an increased risk of ASCVD (table 1), treatment of the primary disease. (See "Overview of risk factors for development of atherosclerosis and early cardiovascular disease in childhood", section on 'Other conditions'.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Jane Newburger, MD, MPH, and Michael Mendelson, MD, ScM, who contributed to an earlier version of this topic review.

  1. American Academy of Pediatrics. Cardiovascular risk reduction in high-risk pediatric populations. Pediatrics 2007; 119:618.
  2. McCrindle BW, Urbina EM, Dennison BA, et al. Drug therapy of high-risk lipid abnormalities in children and adolescents: a scientific statement from the American Heart Association Atherosclerosis, Hypertension, and Obesity in Youth Committee, Council of Cardiovascular Disease in the Young, with the Council on Cardiovascular Nursing. Circulation 2007; 115:1948.
  3. 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.
  4. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents, National Heart, Lung, and Blood Institute. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: summary report. Pediatrics 2011; 128 Suppl 5:S213.
  5. Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics 2017; 140.
  6. Thompson M, Dana T, Bougatsos C, et al. Screening for hypertension in children and adolescents to prevent cardiovascular disease. Pediatrics 2013; 131:490.
  7. Franks PW, Hanson RL, Knowler WC, et al. Childhood obesity, other cardiovascular risk factors, and premature death. N Engl J Med 2010; 362:485.
  8. Sundström J, Neovius M, Tynelius P, Rasmussen F. Association of blood pressure in late adolescence with subsequent mortality: cohort study of Swedish male conscripts. BMJ 2011; 342:d643.
  9. Gray L, Lee IM, Sesso HD, Batty GD. Blood pressure in early adulthood, hypertension in middle age, and future cardiovascular disease mortality: HAHS (Harvard Alumni Health Study). J Am Coll Cardiol 2011; 58:2396.
  10. American Diabetes Association. Management of dyslipidemia in children and adolescents with diabetes. Diabetes Care 2003; 26:2194.
Topic 5753 Version 46.0

آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟