Pediatric Foundations of Heart Disease
- Heart disease, atherosclerosis, hypertension and diabetes begins in childhood and adolescence.1 Since lifestyle and behaviors that influence heart disease also begins in childhood, some of the energy directed toward drugs and cardiac interventions that are critically important in caring for patients with advanced heart disease needs to be directed toward children and asymptomatic individuals who are also at risk.2
- Cardiovascular risk factors in childhood predict accelerated atherosclerosis later in life, independent of current risk factors. Children with persistently abnormal lipid profile (high cholesterol and low HDL) have progression of silent heart disease than those who had favorable lipid profile as adult.3 (See Pediatric dyslipidemia). This supports for intervention programs targeting risk factors in childhood.3
- Autopsy studies have shown significant correlation between risk factors and actual disease in the arteries in children and young adults.4 Significant atherosclerosis was found in young soldiers killed in Vietnamese and Korean wars with 70% showing significant disease in the third decade of life.5, 6
- Atherosclerosis is a systemic disease that is responsible for most cardiovascular events such as heart attack and stroke. Epidemiologic studies and intervention trials based on the incidence these events require years of follow-up, the participation of large populations, or both. Clinical trials of risk intervention in youth with cardiovascular outcomes measured 5 to 6 decades later will never be performed because of the cost and complexities of such studies. 2
- The use of surrogate markers, therefore, is of paramount relevance because it allows researchers to have reliable data in less time and from reduced populations.7 Carotid intima-media thickness (CIMT) measured by B-mode ultrasound is the most studied surrogate marker of subclinical atherosclerosis (silent heart disease) and has been validated by official medical agencies.7
- The researchers examined the influence of age on the associations between childhood risk factors and adult CIMT, among 4380 participants 3 to 18 years old at baseline who were reexamined 13 to 28 years later. On the basis of this data, risk factor measurements obtained at or after 9 years of age are predictive of subclinical atherosclerosis in adulthood.8
- A consistent finding across all subclinical atherosclerosis studies conducted in any age group is that the absence of cardiovascular risk factors is associated with low likelihood of subclinical atherosclerosis. Conversely, the acquisition of obesity, low physical fitness, and tobacco have been shown to be associated with worsening of cardiovascular risk.9
- Children, spouses and close relatives often share a similar gene-environment profile (diet, activity levels and other lifestyle choices). Discovering that a child has high cholesterol should therefore lead to the testing of his or her immediate relatives, and vice versa.
- The pediatric origin of atherosclerosis is now well accepted, with several authorities issuing guidelines and consensus statements for the assessment and management of cardiovascular disease risk factors, including lipids and lipoprotein, blood pressure, and adiposity, in childhood.
1. Berenson GS, Srinivasan SR. Prevention of atherosclerosis in childhood. Lancet. Oct 9 1999;354(9186):1223-1224.
2. Weir GC. Which comes first in non-insulin-dependent diabetes mellitus: insulin resistance or beta-cell failure? Both come firstcomment]. Jama. 1995;273(23):1878-1879.
3. Juonala M, Viikari JS, Kahonen M, et al. Life-time risk factors and progression of carotid atherosclerosis in young adults: the Cardiovascular Risk in Young Finns study. Eur Heart J. Jul 2010;31(14):1745-1751.
4. Wissler RW, Strong JP. Risk factors and progression of atherosclerosis in youth. PDAY Research Group. Pathological Determinants of Atherosclerosis in Youth. Am J Pathol. Oct 1998;153(4):1023-1033.
5. Enos WF, Beyer JC. Coronary artery disease in younger men. Jama. 1971;218(9):1434.
6. McNamara JJ, Molot MA, Stremple JF, Cutting RT. Coronary artery disease in combat casualties in Vietnam. Jama. May 17 1971;216(7):1185-1187.
7. Coll B, Feinstein SB. Carotid intima-media thickness measurements: techniques and clinical relevance. Curr Atheroscler Rep. Oct 2008;10(5):444-450.
8. Juonala M, Magnussen CG, Venn A, et al. Influence of Age on Associations Between Childhood Risk Factors and Carotid Intima-Media Thickness in Adulthood: The Cardiovascular Risk in Young Finns Study, the Childhood Determinants of Adult Health Study, the Bogalusa Heart Study, and the Muscatine Study for the International Childhood Cardiovascular Cohort (i3C) Consortium. Circulation. Dec 14 2010;122(24):2514-2520.
9. Gidding SS. Assembling evidence to justify prevention of atherosclerosis beginning in youth. Circulation. Dec 14 2010;122(24):2493-2494.