Pediatric Risk Factors

• Atherosclerosis begins in childhood and fatty streaks, the earliest lesions, can be identified in the arterial beds of most adolescents. Rapid progression of these early lesions to fibrous plaques occurs in the third and fourth decades of life, with the rate of progression directly associated with the number of cardiovascular risk factors.¹ 

• Carotid atherosclerosis probably develops later than coronary atherosclerosis. Higher carotid intimal medial thickness (IMT) in adults has been consistently associated  silent heart disease as well as with future cardiovascular morbidity in adults in the form of heart attack or stroke.¹

• The specific factors that are highly predictive of silent heart disease include  LDL  (low-density lipoprotein) cholesterol, HDL (high-density lipoprotein)  cholesterol, blood pressure, and obesity Furthermore,  the more of these risk factors one,  the higher the likelihood of having high IMT. A 9-year-old obese child with 2 other risk factors would be twice as likely as a child with no cardiovascular risk factors to have silent heart disease ( as measured by a high a carotid IMT measurement).² 

• These findings support for a population-wide approach to cardiovascular risk reduction beginning in youth. Without such strategies (particularly for obesity prevention) that can be implemented population-wide, the limitation of atherosclerosis development cannot be achieved.¹

• It has now been firmly established that 9 years of age is a crucial year. The identification of the presence of a cardiovascular risk factor at this age has definite implications for future development of cardiovascular disease. ^{2, 3}

• Three ongoing prospective studies have conclusively demonstrated that risk factors that are identified in children are predictive of adult level of risk factors and as well as CVD.^{4, 5} On the other hand, low levels of risk factors during childhood markedly reduce a person’s risk of Cardiovascular disease as an adult.

• Obesity, inactivity, hypertension, dyslipidemia, metabolic syndrome, prediabetes, and diets laden with saturated fats and refined sugar all form an interrelated cluster of risk factors that worsen one another’s effects, feeding back into each other like a flow chart with multiple loops.²

• In healthy preschool children, parental smoking is an independent risk factor for higher blood pressure, adding to other familial and environmental risk factors.⁶ Implementing smoke-free environments at home and in public places may provide a long-term cardiovascular benefit even to young children.

• We know childhood BP tracks to adult BP, so the most important conclusion here is that if you avoid risk factors—such as secondhand smoke—as a child, you will have lower BP and probably lower BP values as an adult.

• The findings complete the picture of tobacco exposure interfering with cardiovascular maturation and health from gestation to adulthood.  Parents should be counseled to stop smoking, as the benefits would likely extend even to the youngest family members. And at the very least, a strictly smoke-free environment should be implemented in the home.

• Over 50% of school children in India, both boys and girls, regularly or sometimes use tobacco, putting their cardiovascular health at serious risk.

• Ultrasound (which is used to measure carotid artery thickness) and EBCT (used to measure plaque calcification) are both sensitive, noninvasive, repeatable tests that can be done to monitor atherosclerosis progression in a child or young adult.⁷ 

Sources

1. Gidding SS. Assembling evidence to justify prevention of atherosclerosis beginning in youth. Circulation. Dec 14 2010;122(24):2493-2494.

2. 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.

3. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. Aug 2004;114(2 Suppl 4th Report):555-576.

4. Davis PH, Dawson JD, Riley WA, Lauer RM. Carotid intimal-medial thickness is related to cardiovascular risk factors measured from childhood through middle age: The Muscatine Study. Circulation. Dec 4 2001;104(23):2815-2819.

5. Morrison JA, Friedman LA, Gray-McGuire C. Metabolic syndrome in childhood predicts adult cardiovascular disease 25 years later: the Princeton Lipid Research Clinics Follow-up Study. Pediatrics. Aug 2007;120(2):340-345.

6. Simonetti GD, Schwertz R, Klett M, Hoffmann GF, Schaefer F, Wuhl E. Determinants of blood pressure in preschool children: the role of parental smoking. Circulation. Jan 25 2011;123(3):292-298.

7. 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.