Version July 2025
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 "Overview of pediatric risk factors for premature atherosclerotic cardiovascular disease (ASCVD)".)
●(See "Dyslipidemia in children and adolescents: Definition, screening, and diagnosis".)
●(See "Dyslipidemia in children and adolescents: Management".)
●(See "Familial hypercholesterolemia in children".)
●(See "Hypertension in children and adolescents: Nonemergency treatment".)
●(See "Prevention and management of childhood obesity in the primary care setting".)
●(See "Overview of the management of type 1 diabetes mellitus in children and adolescents".)
●(See "Management of type 2 diabetes mellitus in children and adolescents".)
RATIONALE FOR INTERVENTION —
Large, prospective, population-based studies and randomized trials in adult patients demonstrate that reducing risk factors associated with ASCVD decreases the incidence of future ASCVD events. (See "Overview of established risk factors for cardiovascular disease", section on 'Established risk factors for atherosclerotic CVD'.)
Similar long-term interventional studies or 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 pediatric risk factors for premature atherosclerotic cardiovascular disease (ASCVD)", section on 'Association between pediatric risk factors and adult ASCVD'.)
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 '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 pediatric risk factors for premature atherosclerotic cardiovascular disease (ASCVD)", 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 pediatric risk factors for premature atherosclerotic cardiovascular disease (ASCVD)".)
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 and algorithm 2B) 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 "Hypertension in children and adolescents: Definition and diagnosis".)
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], longitudinal studies have shown that hypertension in childhood and adolescence is an independent predictor for ASCVD in adulthood [7-11].
The treatment of hypertension in children and adolescents is discussed in greater detail separately. (See "Hypertension in children and adolescents: Nonemergency treatment".)
Insulin resistance and diabetes mellitus — Insulin resistance, hyperinsulinemia, and elevated blood glucose are associated with 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 "Type 1 diabetes mellitus in children and adolescents: Screening and management of complications and comorbidities" 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 [4,5,12]. (See "Type 1 diabetes mellitus in children and adolescents: Screening and management of complications and comorbidities" 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 — Studies involving children and adults have shown that engaging in daily moderate or vigorous physical activity and limiting sedentary behavior improve cardiovascular health and reduce the risk of ASCVD in adulthood. Age-based goals for daily physical activity for children are summarized in the table (table 6) and discussed in greater detail separately. (See "Pediatric prevention of adult cardiovascular disease: Promoting a healthy lifestyle and identifying at-risk children", section on 'Physical activity' and "Prevention and management of childhood obesity in the primary care setting", section on 'Physical activity goals' and "Physical activity and strength training in children and adolescents: An overview", section on 'Benefits of regular physical activity'.)
For 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 appropriate, specific, measurable (if relevant), and clear to both the patient and parents/caregivers.
We also stress the importance of limiting sedentary behavior, especially recreational screen time (eg, computer, video games, mobile devices, television).
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 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 and 30-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.
●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".)
●Encouraging regular physical activity (table 6). (See 'Activity and inactivity' above.)
●Counseling for weight reduction in children and adolescents who are overweight or obese. (See "Prevention and management of childhood obesity in the primary care setting".)
●Counseling for smoking cessation for patients or household members who smoke, prevention of secondhand smoke exposure, and avoidance of initiation of nicotine use, including vaping. (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 "Hypertension in children and adolescents: Definition and diagnosis", section on 'Screening of blood pressure' and "Hypertension in children and adolescents: Nonemergency treatment".)
●For patients with type 1 or type 2 diabetes mellitus, targeting age-appropriate goals for hemoglobin A1c levels (<7 percent in most cases) and screening for and managing other associated ASCVD risk factors. (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".)
●For patients with underlying conditions that are associated with an increased risk of ASCVD (table 1), treatment of the primary disease and screening for additional ASCVD risk factors. This generally involves earlier and more frequent lipid screening and using lower thresholds for initiating lipid-lowering therapy (algorithm 1). (See "Overview of pediatric risk factors for premature atherosclerotic cardiovascular disease (ASCVD)", 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 pediatric risk factors for premature atherosclerotic cardiovascular disease (ASCVD)".)
●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 pediatric risk factors for premature atherosclerotic cardiovascular disease (ASCVD)", 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):
•Promoting a heart-healthy diet rich in vegetables, fruits, and whole grains; sufficient in heart-healthy fats; low in saturated fat; and devoid of trans fats (table 8). (See "Dietary recommendations for toddlers and preschool and school-age children".)
•Encouraging regular 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 "Prevention and management of childhood obesity in the primary care setting", section on 'Physical activity goals' and "Physical activity and strength training in children and adolescents: An overview", section on 'Benefits of regular physical activity'.)
•Counseling for weight reduction in children and adolescents who are overweight or obese. (See "Prevention and management of childhood obesity in the primary care setting".)
•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 "Hypertension in children and adolescents: Definition and diagnosis", section on 'Screening of blood pressure' and "Hypertension in children and adolescents: Nonemergency treatment".)
•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 underlying conditions that are associated with an increased risk of ASCVD (table 1), treatment of the primary disease and screening for additional ASCVD risk factors. (See "Overview of pediatric risk factors for premature atherosclerotic cardiovascular disease (ASCVD)", 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.
