Published onChildren's Doctor
Case: Ethan is 16-year-old male who presents to the Lipid Heart Clinic for further evaluation of his dyslipidemia. Past history reveals an otherwise healthy adolescent who experienced a 50-pound weight gain over the past year without height increase. A fasting lipid profile was obtained as part of the workup for the weight gain. Family history is significant for his dad with severe obesity now 1-year post bariatric surgery. His mom has hypercholesterolemia, and the maternal grandfather had a myocardial infarction at age 52 years. Ethan’s diet consists of a high-sugar cereal with 1% milk for breakfast. He buys school lunch or eats leftovers when he is learning from home. Dinners include meat, potatoes or rice, and vegetables. Snacks include ramen noodles, chips, and ice cream. He drinks chocolate milk, water, and iced tea. He participates in gym class twice a week. His sedentary time is several hours per day. Ethan denies cardiovascular complaints, specifically no chest pain, palpitations, dizziness, or syncope. He tires easily but is able to go on walks with his mom.
Physical examination reveals height 169 cm (28th%), weight 114.6 kg (> 99th%), BMI 40.13 kg/m2 (146% of 95th%), blood pressure 118/64, heart rate 86 bpm. He has abdominal and upper thigh striae and faint acanthosis nigricans around the neck and axillae. The fasting lipid panel showed total cholesterol 212 mg/dL, LDL-c 122 mg/dL, triglycerides (TG) 280 mg/dL, HDL-c 34 mg/dL, non-HDL-c 178 mg/dL. Due to the hypertriglyceridemia and high non-HDL-c, he was started on high-dose omega-3 fatty acids and was referred to the Cardiovascular Risk Assessment Clinic.
Who is at risk for premature cardiovascular disease?
Cardiovascular disease (CVD) is the leading cause of death in the United States. Identifying children at increased CVD risk is important as there are interventions available. While all children should have routine cardiovascular health screening (Expert Panel 2011), certain risk factors and conditions predispose children to premature CVD and should be evaluated more frequently. Table 1 stratifies patients with certain conditions into categories by the amount of atherosclerotic risk compared to the general population. There are those who have traditional risk factors in childhood, while others have certain medical conditions that increase CVD risk.
Assessing CVD risk
For patients who are considered at increased risk, CVD risk factors should be evaluated at time of diagnosis and, if normal, on a yearly basis at minimum (see Table 2). If any of these are abnormal, then further evaluation should occur. Depending on the risk factor and the severity, initial intervention is commonly dietary and lifestyle changes with repeat evaluation 6 to 8 weeks later. If still abnormal, a referral to the Preventive Cardiovascular Program or other subspecialty clinic may be considered.
The Preventive Cardiovascular Program
The Preventive Cardiovascular Program was formed in 2019 in response to the need for a comprehensive CVD risk reduction program. The program encompasses two well-established clinics, Lipid Heart Clinic and Hypertension Clinic, and a new clinic, the Cardiovascular Risk Assessment (CVRA) Clinic. The CVRA Clinic’s emphasis is on evaluating patients as young as age 10 years in the risk categories shown in Table CVD risk is assessed through testing, including electrocardiography, echocardiography, and vascular ultrasound imaging; reviewing blood pressure and BMI; and reviewing lipids and other lab work. The main focus is on dietary and lifestyle changes. The patient and family meet with our dietitian and exercise physiologist, who provide a personalized program for the patient to follow with routine virtual and in-person check-ins subsequent to the initial visit.
Case study update: CVRA clinic visit
Ethan’s cardiovascular risk factors were assessed and included: mixed dyslipidemia, severe obesity, low physical activity levels, high amount of sedentary time, and family history of premature CVD. At his CVRA Clinic visit, vascular studies were performed and were within normal limits for age and gender. His echocardiogram showed normal biventricular function and left ventricular size and mass. A Healthy Weight Program referral was made for ongoing weight management. After the initial meeting with the CVRA dietitian and exercise physiologist, Ethan has been communicating with them every 1 to 2 weeks. He decreased his sugar drink consumption, is utilizing the FitBit that was provided for step counting, and has lost 10 pounds. Repeat lipid labs showed a decrease in his TG and non-HDL-C levels.
Table 1: Disease Stratification by Risk
- High risk: Homozygous familial hypercholesterolemia, type 1 and 2 diabetes, end-stage renal disease, Kawasaki disease with current aneurysm, solid organ transplant vasculopathy, childhood cancer survivor (stem cell recipient).
- Moderate risk: Severe obesity (BMI ≥120% of the 95th percentile or an absolute BMI ≥35 kg/m2, whichever is lower based on age and sex), heterozygous familial hypercholesterolemia, elevated lipoprotein (a), aortic coarctation, aortic stenosis, confirmed hypertension, predialysis chronic kidney disease, childhood cancer survivor (chest radiation).
- At risk: Obesity (BMI > 95th%), insulin resistance with comorbidities, white-coat hypertension, cardiomyopathies, pulmonary hypertension, s/p coronary artery translocation for anomalous coronary arteries or transposition of the great arteries, Kawasaki disease with regressed aneurysms, chronic inflammatory conditions (JIA, SLE, IBD, HIV), childhood cancer (cardiotoxic chemotherapy only).
Table 2: Cardiovascular Risk Factors and How to Assess
- Dyslipidemia: Fasting or nonfasting lipid profile
- Body Mass Index (BMI): Height and weight
- Hypertension: Blood pressure (3 separate occasions)
- Diabetes: Fasting blood sugar
- Family history of early CVD: Question parent/patient
- Smoking, including second-hand: Question parent/patient
- Physical activity/Sedentary time: Question parent/patient
References and suggested reading
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:e603-634.
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):S213-256.
Kavey RE, Allada V, Daniels SR, et al. Cardiovascular risk reduction in high-risk pediatric patients: a scientiﬁc statement from the American Heart Association Expert Panel on Population and Prevention Science; the Councils on Cardiovascular Disease in the Young, Epidemiology and Prevention, Nutrition, Physical Activity and Metabolism, High Blood Pressure Research, Cardiovascular Nursing, and the Kidney in Heart Disease; and the Interdisciplinary Working Group on Quality of Care and Outcomes Research. Circulation. 2006;114:2710-2738.