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Identifying the child at-risk for atherosclerosis

INTRODUCTION

Although cardiovascular disease (CVD) is generally manifest in adulthood, the process of atherosclerosis can begin early in childhood. For most children, atherosclerotic vascular changes are minor and can be minimized or even prevented with adherence to a healthy lifestyle. However, in some children, the process is accelerated because of the presence of identifiable risk factors (eg, obesity and hypertension) and/or specific diseases that are associated with premature CVD (eg, diabetes mellitus and Kawasaki disease) [1].

Identification of children who are at-risk for atherosclerosis may allow timely intervention to decrease the atherosclerotic process, thereby preventing or delaying CVD [1-3].

Identifying the child at-risk for atherosclerosis and assessing his/her risk for CVD will be reviewed here. The management of the child at-risk for atherosclerosis and the pediatric diseases associated with an increased risk of atherosclerosis are discussed separately. (See "Management of the child at-risk for atherosclerosis" and "Diseases associated with atherosclerosis in childhood".)

ATHEROSCLEROTIC CHANGES IN CHILDHOOD

Autopsy studies in children and young adults who have died of noncardiovascular causes demonstrated early development of atherosclerosis, with initial finding of fatty streaks (accumulation of lipid-filled macrophages within the intima of the artery) and later development of fibrous plaque, as illustrated by the following [4,5]:

  • In the Bogalusa Heart Study, fatty streaks and fibrous plaques were found in autopsies performed in 204 young patients ranging from 2 to 39 years of age [4]. The prevalence and the extent of atherosclerosis found in the aorta and coronary arteries was greater with increasing age, body-mass index (BMI), blood pressure measurements, and levels of serum total cholesterol and low-density lipoprotein cholesterol (LDL-C). The degree of involvement increased with worsening severity and greater numbers of risk factors.
  • The Pathobiological Determinants of Atherosclerosis in Youth (PDAY) study examined the right coronary arteries and aortas in autopsies of 2876 individuals between 15 and 34 years of age [5,6]. In subjects who were 15 to 19 years of age, raised fatty streaks, accumulation of lipid-filled macrophages within the intima of the artery, were present in 10 percent of coronary arteries and 30 percent of aortas. The extent of fatty streaks increased with older age, elevated blood pressure, higher serum low-density lipoprotein cholesterol (LDL-C), and lower serum high-density lipoprotein (HDL-C) cholesterol. In a subsequent report, individuals with early and more severe atherosclerotic changes were more likely to have had one or more of the following known adult CVD risk factors: dyslipidemia, smoking, hypertension, obesity, and hyperglycemia [7].
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