Preventive Cardiology Clinic

Cardiovascular disease (CVD) is the single largest cause of morbidity and mortality in the U.S. Obesity is a major acquired contributor to CVD that will undoubtedly overburden our healthcare system and all of us as health care providers in the coming years. Roughly 20 percent of children have abnormal lipid levels.

Below are guidelines from the Preventive Cardiology Program and the National Heart Lung and Blood Institute (NHLBI) that may help you manage your approach to cardiovascular disease (CVD) risk reduction in your patients. In a single document, these guidelines raise consciousness about both genetic disorders and obesity-related lifestyle characteristics.

Screening can begin with oscillometric BP, but diagnosis and treatment decisions should be made based on auscultated BP in the right arm.

Approach for evaluation and treatment is includes DASH diet (low added salt and sugar, high fruits and vegetables, lean proteins), assessing and addressing stress, and in some cases pharmacotherapy.

Why do a lipid screening?

• Identifies familial hyperlipidemias (FH) associated with early cardiovascular disease. FH are present in 1 in 250 children, but are asymptomatic until there is myocardial ischemia. Individuals with FH who are untreated have a risk of premature coronary heart disease at least 20 times greater than those without FH. (Of note, one study suggests the risk of cardiac events in FH can be reduced to that of the general adult population by statin therapy, but only if these lipid disorders are identified early.)
• Diagnoses non-genetic LDL lipid disorders that require lifestyle modification. NHANES data suggest one in five adolescents in the U.S. has an abnormal lipid level of some type (JAMA 2010, MMWR Morb Mortal Wkly Rep. 2010 Jan 22:59(2): 29-33. Prevalence of abnormal lipid levels among youths. United States, 1999-2006. Centers for Disease Control and Prevention [CDC)].)

Who needs a lipid screening?

• Screen all children once between ages 9 and 11, and again once between 17 and 21 years.
• Selectively screen high-risk patients (individuals with a family history of early CVD events or other CVD risk factors) starting at age 2.

Which type of lipid screening is appropriate?

• Screen with a fasting lipid profile OR non-fasting TC and HDL to calculate non-HDL cholesterol levels.
• If non-fasting non-HDL cholesterol is ≥ 145 mg/dL, or HDL < 40 mg/dL, obtain fasting lipid profile.

Lipid management recommendations

• Refer to specialist directly for LDL ≥ 250 mg/dL or fasting TG≥ 500 mg/dL.
• Initial treatment for nearly all patients is six months of targeted lifestyle change, which in some cases can be done through primary care.
• Treat high TG differently from high LDL, both in terms of nutrition counseling and pharmacotherapy (guidelines include useful tables and algorithms to guide treatment).
• Use lipid-lowering medications in patients who have not responded to six months of lifestyle counseling and have LDL ≥190 mg/dL; use somewhat lower LDL cutpoints for patients with high-risk conditions
• Recommended age for pharmacotherapy is ≥ 10 years, except in very high-risk cases.

Acceptable, borderline-high, and high plasma lipid, lipoprotein and apolipoprotein concentrations (mg/dL) for children and adolescents*

NOTE: Values given are in mg/dL; to convert to SI units, divide the results for TC, LDL-C, HDL-C and non-HDL-C by 38.6; for TG, divide by 88.6.

* Values for plasma lipid and lipoprotein levels are from the National Cholesterol Education Program (NCEP) Expert Panel on Cholesterol Levels in Children. Non-HDL-C values from the Bogalusa Heart Study are equivalent to the NCEP Pediatric Panel cut points for LDL-C. Values for plasma apoB and apoA-1 are from the National Health and Nutrition Examination Survey III.

+ The cut points for high and borderline-high represent approximately the 95th and 75th percentiles, respectively. Low cut points for HDL-C and apoA-1 represent approximately the 10th percentile.

We are interested in discussing these issues with you. As primary care providers who are experts in screening and health maintenance, your perspective and experience are extremely important and valuable to us. To consult with one of our pediatric preventive cardiologists, please call 617-355-0955, or email preventivecardio@cardio.chboston.org.