Pediatric Preventive Cardiology Research Articles

Toward a Roadmap for Best Practices in Pediatric Preventive Cardiology: A Science Advisory From the American Heart Association.

Cardiovascular disease risk factors are highly prevalent among youth in the United States and Canada. Pediatric preventive cardiology programs have independently developed and proliferated to address cardiovascular risk factors in youth, but there is a general lack of clarity on best practices to optimize and sustain desired outcomes. We conducted surveys of pediatric cardiology division directors and pediatric preventive cardiology clinicians across the United States and Canada to describe the current landscape and perspectives on future directions for the field. We summarize the data and conclude with a call to action for various audiences who seek to improve cardiovascular health in youth, reduce the burden of premature cardiovascular disease, and increase healthy longevity. We call on heart centers, hospitals, payers, and policymakers to invest resources in the important work of pediatric preventive cardiology programs. We urge professional societies to advocate for pediatric preventive cardiology and provide opportunities for training and cross-pollination across programs. We encourage researchers to close evidence gaps. Last, we invite pediatric preventive cardiology clinicians to collaborate and innovate to advance the practice of pediatric preventive cardiology.

The influence of somatic maturity on the relationship between the triglyceride/high-density lipoprotein ratio and vascular health in children and adolescents with dyslipidemia.

Both the triglyceride to HDL cholesterol (TG/HDL) ratio and timing of pubertal maturation have been identified as independent contributors to the development of atherosclerosis. The purpose of our study was to determine the relationship between the TG/HDL ratio and measures of vascular health in children and adolescents with dyslipidemia stratified by somatic maturity. We hypothesized that somatic maturity would have a significant interaction with TG/HDL ratio and vascular health. This was a longitudinal analysis of 120 children and adolescents (age 8-14 years) with dyslipidemia recruited from a pediatric preventive cardiology clinic. At baseline and each follow-up visit, a non-fasting serum lipid panel was collected and vascular health (carotid artery intima--media thickness, pulse wave velocity, augmentation index) was assessed. Peak height velocity (PHV) was calculated at each visit, and participants were stratified into groups by maturity offset (pre-PHV, mid-PHV, post-PHV). A mixed model design permitted baseline and follow-up visits to be classified as discrete data points. Of the n=235 data points (pre-PHV=23%, mid-PHV=19%, and post-PHV=58%), we identified no significant interaction between TG/HDL ratio, maturity offset, and measures of vascular structure or function. There was also no significant relationship found between TG/HDL and maturity group. Within the mid-pubertal group, there was weak relationship found between TG/HDL and augmentation index. Despite the well-described relationship between early pubertal maturation and development of cardiovascular risk factors in adulthood, we found that vascular damage resulting from an elevated TG/HDL ratio is not independently associated with somatic maturity.

Statin adherence and LDL-C reduction in a pediatric population

Statins have demonstrated efficacy and safety in children with primary dyslipidemias such as familial hypercholesterolemia; however, adherence plays a key role in the ability of a statin to lower low-density lipoprotein cholesterol (LDL-C) levels. The objective of this study was to examine the role medication adherence plays in statin efficacy for the treatment of primary and secondary pediatric dyslipidemias. Retrospective review of a pediatric preventive cardiology database identified all subjects <22 years old who were prescribed a statin. Dosing, adverse effects, pre- and on-treatment LDL-C levels, medication adherence, and family history of atherosclerotic cardiovascular disease (ASCVD) were recorded. Adherence to medication was considered adequate if subject self-reported taking ≥80% of prescribed doses in the 14 days prior to lowest treatment LDL-C value. Chart review identified 131 subjects aged 6–21 years prescribed a statin with pre- and on-treatment data available. Of these 131 subjects, 123 (94%) had LDL-C > 130 mg/dL before beginning a statin. On treatment, 100/131 subjects (76%) met the LDL-C target of ≤130 mg/dL. Of 83 subjects with adherence data available, 61 (73%) met the adherence threshold and the adherent group had significantly greater mean reduction in LDL-C compared to the non-adherent group (−91 mg/dL versus −20 mg/dL, p = .0001). There were no reported adverse effects. These findings indicate that reductions in LDL-C were dependent on medication adherence. Utilizing a model of early intervention, family education, and intensive follow-up to improve adherence may improve clinical outcomes and reduce future ASCVD events in children with primary and secondary dyslipidemias that require lipid-lowering therapy.

Abstract P100: Improving Ideal Cardiovascular Health in a Pediatric Preventive Cardiology Practice

Introduction: Achieving ideal cardiovascular health (iCVH) for children necessitates both public health and individual interventions. Hypothesis: We hypothesized that children referred to a multidisciplinary preventive cardiology clinic would demonstrate improved iCVH after clinic-based lifestyle counseling. Methods: We analyzed data from youth ages 8-19 years seen for ≥2 consecutive visits in the Boston Children’s Hospital Preventive Cardiology clinic between 2010-2017. Demographic information, smoking status, diet, and physical activity were self-reported. Anthropometric data, blood pressure, fasting cholesterol, and fasting glucose were measured using standard protocols. We applied AHA definitions of ideal, intermediate, and poor iCVH with minor adaptations to data extracted from a clinical registry. Each iCVH metric had a possible range of 0 (poor) to 2 (ideal); the total iCVH score could range from 0 (all poor) to 14 (all ideal). Results: Median age of the 767 children in the study was 12.5 years [IQR 10.2,15.9]; 414 (54%) were female and 32 (5%) had a moderate or high CVD risk condition (diabetes, renal disease, Kawasaki, congenital heart disease, or heart transplant). Over a median of 3.9 [IQR 3.2, 6.0] months from initial assessment to first follow-up, mean iCVH score improved from 7.7 (SD 2.2) to 8.1 (SD 2.2) (p &lt; 0.001). Females had higher iCVH scores at baseline and follow-up (females 7.9 to 8.4 vs. males 7.5 to 7.9, p&lt;0.001), as did children younger than 14 years of age (data not shown). iCVH score improved to a mean of 8.3 (SD 2.4) for the 449 children returning for a third visit. The largest improvement was observed in total cholesterol and dietary habits (Figure); only 61 (8%) of children were prescribed statin therapy. Conclusion: Multidisciplinary clinical care can improve the iCVH of children who present with non-optimal levels, largely without the use of medications. Further work is needed to determine the scalability and long-term effectiveness of cardiovascular health promotion efforts in pediatric care.

Modifiable Clinical Correlates of Vascular Health in Children and Adolescents with Dyslipidemia.

Atherosclerosis promoting cardiovascular disease risk factors (CVDrf) are highly prevalent among youth in the U.S. Determining which standard modifiable clinical measures (SMCMs) has the greatestimpact onvascular structure and function is valuable for the health care provider to help identify children at highest risk. The aim of this study was to determine modifiable outpatient clinical predictors of vascular health in youth with CVDrf. Children and adolescents with CVDrf (n = 120, 13.1 ± 1.9 years, 49% female) were recruited from a pediatric preventive cardiology clinic. The SMCMs included BMI z-score, waist-to-height ratio (WTHR), lipid panel, hemoglobin A1c, blood pressure (BP), presence of tobacco smoke exposure, and presence of hypertriglyceridemic waist (HTW) phenotype (triglycerides ≥ 110mg/dL and waist circumference ≥ 90 percentile). Vascular function and structure were measured with pulse wave velocity (PWV), central systolic BP (CSP), augmentation index (AIx), and carotid artery intima-media thickness (cIMT). Sex and height specific z-scores for PWV, CSP, and cIMT were used. Multiple linear regression with backwards selection identified SMCMs which strongly predicted vascular function and structure. Among SMCMs, WTHR and HTW were the most frequent predictors of vascular function (PWV: R2 = 0.32; CSP: R2 = 0.35; AIx R2 = 0.13). Other predictors of vascular function included hemoglobin A1C, BP, and BMI z-score. Systolic BP and LDL cholesterol were predictors of vascular structure (cIMT: R2 = 0.14). The strongest predictors of vascular health in youth with CVDrf were related to measures of central obesity. Targeting these SMCM in lieu of vascular testing in outpatient clinic setting may be practical to identify children and adolescents at greatest risk for CVD.

The Role of Exercise Prescription in Pediatric Preventive Cardiology Programs.

Lifestyle changes such as exercise and dietary change are recommended first-line therapy for children with dyslipidemia, hypertension, and obesity. Although most clinicians recommend exercise, specific exercise prescriptions are not usually provided. The optimal type, duration, and intensity of activity to achieve a meaningful outcome is not definitively defined. As the pediatric population becomes more sedentary and morbidity accumulates from this lifestyle, understanding how targeted exercise prescriptions can benefit patients will be critical to effectively manage this group of patients. This review focuses on the role of exercise for the treatment of pediatric patients with dyslipidemia, hypertension, and obesity and describes additional factors that require future research to achieve desired outcomes in this at-risk population. [Pediatr Ann. 2018;47(12):e494-e498.].

Abstract P093: Correlates of Vascular Health in Children and Adolescents With Dyslipidemia

Introduction: Impaired vascular function and structure has been associated with cardiovascular risk factors such as elevated levels of Low Density Lipoprotein cholesterol (LDL-C) and triglycerides, depressed High Density Lipoprotein cholesterol (HDL-C), elevated blood pressure (BP) and body mass index (BMI) in children and young adults. These changes can result in premature coronary artery disease. The degree to which these measures predict vascular damage in children and adolescents is less clear. Hypothesis: We hypothesized that commonly used clinical and laboratory measures will predict vascular health as assessed by measures of carotid artery intima-media thickness (CIMT), pulse wave velocity (PWV), and augmentation index (Aix) in at risk youth. Methods: Children and adolescents with dyslipidemia (n=120, 13.1 ± 1.9 years old, 49% female (59 of 120)) were recruited from a pediatric preventive cardiology clinic. Non-fasting total cholesterol, HDL cholesterol, and triglycerides were obtained prior to the clinic visit. LDL-C and non-HDL-C were calculated with the Martin equation. Remnant particles were calculated as: total cholesterol minus (HDL-C + LDL-C). BP, height, weight, and waist circumference (WC) were measured at the clinic visit. WC was measured 2cm above the iliac crest by a single observer. Tobacco smoke exposure history was obtained using a parent questionnaire. PWV and Aix were measured using a SphygmoCor XCEL combined oscillometric and tonometric device. CIMT was measured via B mode ultrasound on the far wall of the left and right common carotid arteries using a semi-automated edge detection software. Multiple linear regression with backwards selection was used to identify the strongest predictors of CIMT, PWV, and normalized Aix. Results: Age (β=0.26; p=0.002), systolic BP (β=0.16; p=0.04), waist-to-height ratio (β=0.24; p=0.01), hemoglobin A1c (β=0.18; p=0.01) and presence of hypertriglyceridemic waist (defined as triglycerides ≥110mg/dL and WC ≥90 percentile) (β=0.28; p=0.006) were the strongest predictors of PWV (R2=0.353). Diastolic BP (β=0.21; p=0.01), waist-to-height percentile (β=0.22; p=0.01), and remnant particles (β=0.21; p=0.01) were the strongest predictors of normalized Aix (R2=0.175). Age (β=0.19; p=0.03), and systolic BP (β=0.28; p=0.002) were the strongest predictors of CIMT (R2=0.138). Triglycerides, history of tobacco smoke exposure, total cholesterol, LDL-C, HDL-C, and non-HDL-C were not predictive of CIMT, PWV, or normalized Aix. Conclusion: BP consistently predicted was the most common predictor of CIMT, PWV, and Aix in children and adolescents with dyslipidemia. Waist-to-height ratio/percentile was also a reliable predictor in both PWV and Aix. BP and abdominal obesity management should be a focus in this at risk population.

Statin-Associated Myopathy in a Pediatric Preventive Cardiology Practice

To describe muscle-related statin adverse effects in real-world pediatric practice. Using prospectively collected quality improvement data from a pediatric preventive cardiology practice, we compared serum creatine kinase (CK) levels among patients prescribed and not prescribed statins, and pre-/poststatin initiation. Multivariable mixed-effect models were constructed accounting for repeated measures, examining the effect of statins on log-transformed CK (lnCK) levels adjusted for age, sex, weight, season, insurance type, and race/ethnicity. Among 1501 patients seen over 3.5 years, 474 patients (14?±?4 years, 47% female) had at least 1 serum CK measured. Median (IQR) CK levels of patients prescribed (n?=?188 patients, 768 CK measurements) and not prescribed statins (n?=?351 patients, 682 CK measurements) were 107 (83) IU/L and 113 (81) IU/L, respectively. In multivariable-adjusted models, lnCK levels did not differ based on statin use (??=?0.02 [SE 0.05], P?=?.7). Among patients started on statins (n?=?86, 130 prestatin and 292 poststatin CK measurements), median CK levels did not differ in adjusted models (? for statin use on lnCK?=?.08 [SE .07], P?=?.2). There was a clinically insignificant increase in CK over time (??=?.08 [SE .04], P?=?.04 per year). No muscle symptoms or rhabdomyolysis were reported among patients with high CK levels. In a real-world practice, pediatric patients using statins did not experience higher CK levels, nor was there a meaningful CK increase with statin initiation. These data suggest the limited utility to checking CK in the absence of symptoms, supporting current guidelines.

Treatment decision making for adolescents with familial hypercholesterolemia: Role of family history and past experiences

Adolescents and young adults (AYAs) with familial hypercholesterolemia (FH) are at high risk for underdiagnosis and inadequate treatment. Yet, little is known about the factors that influence the medical decision making of AYAs with FH and their families. This study explores how family medical history, family narratives of medical experiences, and AYA medical experiences together function as "experiential evidence" and influence screening and treatment decisions. Twenty-four parents and AYAs affected by FH from a pediatric preventive cardiology practice responded to a survey and a semistructured qualitative interview. Transcribed interviews were analyzed using a modified grounded theory approach. Study design, instruments, and interpretation of results were informed by a 20-member stakeholder panel. AYAs and parents reported extensive personal and family experiences with cholesterol and cardiovascular conditions and treatments, sometimes distinct from FH, which were used as evidence to inform their own perceptions of FH risk and treatment. This experiential evidence impacted perceptions of: (1) hereditary risk for FH diagnoses, (2) risk for future cardiovascular disease, (3) risks associated with treatments, and (4) capacity to comply with recommended treatments. Although experiences of family members initially informed screening and treatment decisions, the subsequent personal experiences of AYAs led to new experiential evidence that informed future decisions. Family cardiovascular history related to and distinct from FH influenced screening and treatment decisions of AYAs and parents affected by FH. Additional clinical assessment of personal and family medical experiences may enhance understanding of the decision-making processes among AYAs and ultimately improve adherence to screening and treatment recommendations.

Abstract P138: Lifestyle Goals in Pediatric Preventive Cardiology: Practical Clinical Application

BACKGROUND: Lifestyle change is recommended by the 2011 NHLBI Expert Panel Integrated Guidelines as the cornerstone of pediatric lipid management. Using a Standardized Clinical Assessment and Management Plan (SCAMP)© (IRCDA Inc, Boston MA) as an implementation tool, we examined in a real-world setting the effect of making 3 lifestyle goals on lipid levels in youth referred to a pediatric Preventive Cardiology clinic. METHODS: Prospectively collected anthropometric, clinical, and laboratory data were analyzed on youth referred for lipid abnormalities between September 2010 and March 2014. Percent change in lipid fractions from baseline to last follow-up was calculated. Lifestyle recommendations given at initial visit were predictors of interest considered individually and as groups of 3. Multivariable adjusted linear regression was used to identify lifestyle combination trios that were associated with dyslipidemia change. RESULTS: Among 325 patients (55% female, median follow-up time 17 [IQR 10,28] months; mean age 13±4yrs], high LDL (&gt;130 mg/dL) was present in 62%, high TG (&gt; 150 mg/dL) in 35%, and low HDL (&lt;40 mg/dL) in 28%. In those with the relevant lipid abnormality, LDL decreased by 11±17%, TG declined by 22±35% and HDL improved by 15±35%. Overall, BMI percentile declined by 2 points. The most common lifestyle goals given were ‘decrease saturated/trans fat’ (63%), ‘increase vegetables/fruit’ (61%), ‘increase exercise’ (55%), ‘continue exercise’ (35%), and ‘decrease glycemic index’ (30%). In those with HDL&lt;40 adjusted for age and sex, ‘increase fish and nuts’ was associated with HDL improvement (6.52mg/dL[ 2.38,10.66];p=0.002) but, unexpectedly, ‘increase vegetables/fruit’ was associated with worse HDL (-3.87mg/dL[95%CI-6.75,-0.99]; p=0.01). In those with TG&gt;150 as expected, ‘decrease fast food/eating out’ was associated with lower TG (37%[13,54]; p=0.006). After adjustment for age, sex, baseline lipid level, and BMI percentile change, the trio of ‘increasing vegetables/fruit’, ‘decreasing saturated/trans fat’, and ‘continue exercise’ was associated with lower LDL (-17.64mg/dL[-3.62,-31.56];p=0.01). Intriguingly, substituting ‘increase exercise’ instead of ‘continue exercise’ in this trio was not associated with lipid change. CONCLUSIONS: In a real-world cohort of dyslipidemic youth, providing lifestyle goals was associated with favorable lipid changes, with some combinations showing particular benefits. More data is warranted to explore the effect of specific lifestyle goal combinations in youth.

Hypertension in an Adolescent Secondary to Performance-Enhancement Supplement Use.

Objective: To describe the effects of performance-enhancing supplements and caffeine on the blood pressure (BP) of an adolescent male. Case Summary: An adolescent male presented to his primary care provider for a preseason athletic physical. On physical exam, his BP was 162/90, exceeding the 99th percentile for his age. It had been elevated during the previous 2 yearly physicals. He was referred to the Pediatric Preventive Cardiology Clinic for follow-up. Illegal substance use and renal trauma were ruled out. During the evaluation, the patient acknowledged using energy drinks and performance-enhancing supplements, the majority of which were caffeine-based. His intention was to continue the use of supplements, so lisinopril was initiated. On follow-up, however, the patient reported supplement discontinuation, intermittent medication adherence, and lower home-based BP readings. He was subsequently lost to follow-up. An objective causality assessment revealed that the adverse drug event was probable. Discussion: When working with adolescent patients, it is particularly important to conduct an in-depth interview reflecting lifestyle choices. Use of performance-enhancing supplements and caffeine for adolescent athletes has been well reported in the literature. Adolescent use of supplements may be driven by misguided beliefs and lack of knowledge about potentially detrimental health effects, such as altered heart rate and elevated BP. Little evidence-based research is available to provide treatment guidance for clinicians regarding potential effects. Conclusions: A thorough patient history, including specific questions probing for any recent or chronic use of nutritional supplements, including energy drinks, will help identify substances that may contribute to BP variations. Even mild BP elevations in adolescents should lead clinicians to further investigate supplement use and include specific questions on any product use within the past 24 hours, several days, or longer. Adolescents may not consider the potential for adverse health effects when ingesting performance-enhancing supplements or energy drinks.

Keeping Kids Young at Heart: Development of a Pediatric Preventive Cardiology Clinic*

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PT419 Cardiovascular Risk Factors in a Pediatric Preventive Cardiology Outpatient Clinic: Baseline Results of a Clinical Cohort Study

PT419 Cardiovascular Risk Factors in a Pediatric Preventive Cardiology Outpatient Clinic: Baseline Results of a Clinical Cohort Study

Comparação das curvas NCHS, CDC e OMS em crianças com risco cardiovascular

ObjectiveThe study aimed to compare the prevalence of overweight and obesity according to three growth curves, created by the World Health Organization (WHO/2006), by the National Center for Health Statistics (NCHS/1977), and by the Centers for Disease Control and Prevention (CDC/2000) in children with cardiovascular risk factors. MethodsData from 118 children and adolescents, aged between 2 and 19 years, treated between the years 2001 to 2009 at the Pediatric Preventive Cardiology Outpatient Clinic of the Instituto de Cardiologia de Porto Alegre were evaluated. The variables analyzed were: weight, height, age, and gender. Variables were classified according to the following criteria: weight/age, height/age, and body mass index (BMI). The cutoff points used were obtained from the three growth curves: WHO/2006, NCHS/1977, and CDC/2000. ResultsRegarding the criterion weight/age by the NCHS curve, 18% of the children were classified as having normal weight, and 82% had excess weight; by the CDC curve, 28% had normal and 72% had excess weight; by the WHO curve, 16.0% had normal weight and 84% had excess weight. According to the BMI, 0.8% of the population was underweight. According to the CDC and WHO curves, 7.6% and 6.8% had normal weight; 26.3% and 11.9% were overweight; and 65.3% and 80.5% were obese, respectively. Regarding the height/age criterion, there was no significant difference between the references and, on average, 98.3% of the population showed adequate height for age. ConclusionThe new WHO curves are more sensitive to identify obesity in a population at risk, which has important implications for preventive and therapeutic management.

457 Role of Interferon γ-Inducible Protein 10 in the Pathogenesis of Non-Alcoholic Steatohepatitis

A S L D A b st ra ct s by mass spectrometry to diagnose NAFLD in overweight/ obese children. Methods: Patients were recruited from the Pediatric Preventive Cardiology and Metabolic Clinic. All patients were screened with an ultrasound of the abdomen to evaluate for the presence of NAFLD. Exhaled breath was collected and analyzed per protocol using selective ion flow tube (SIFTMS) to identify new markers of NAFLD. Results: Sixty patients were included in the study (37 with NAFLD on ultrasound and 23 with normal liver). All children were overweight or obese with a body mass index ≥ 85% for age. The mean age was 15± 3.1 years and 50% were female. A comparison of the SIFT-MS results of patients with NAFLD to those with normal liver on ultrasound revealed differences in concentration of more than 15 compounds. Discriminant analysis via stepwise variable selection of mass scanning ion peak data demonstrated five ion peaks that identified subjects with NAFLD with an accuracy of 90% (-2 log likelihood 0.172; Wilks' Lambda 0.145 (p , 0.0001)). Further analysis revealed that breath isoprene (cholesterol synthesis), acetone (glucose metabolism), trimethyamine (choline metabolism by microbiota), acetaldehyde (ethanol metabolism), and pentane (oxidative stress) were significantly higher in the NAFLD group compared to normal liver group, p value, 0.05 for all (Table). Conclusion: Exhaled breath analysis is a promising noninvasive method to detect fatty liver in obese children. Isoprene, acetone, trimethylamine, acetaldehyde, and pentane are novel biomarkers that may help to gain insight into pathophysiological processes and pathways leading to the development of NAFLD. Future studies are needed to validate our findings.

456 TAK1-Mediated Signaling Regulates AMPK and Autophagy Pathways That Prevent Hepatic Steatosis and Hepatocarcinogenesis in Mice

A S L D A b st ra ct s by mass spectrometry to diagnose NAFLD in overweight/ obese children. Methods: Patients were recruited from the Pediatric Preventive Cardiology and Metabolic Clinic. All patients were screened with an ultrasound of the abdomen to evaluate for the presence of NAFLD. Exhaled breath was collected and analyzed per protocol using selective ion flow tube (SIFTMS) to identify new markers of NAFLD. Results: Sixty patients were included in the study (37 with NAFLD on ultrasound and 23 with normal liver). All children were overweight or obese with a body mass index ≥ 85% for age. The mean age was 15± 3.1 years and 50% were female. A comparison of the SIFT-MS results of patients with NAFLD to those with normal liver on ultrasound revealed differences in concentration of more than 15 compounds. Discriminant analysis via stepwise variable selection of mass scanning ion peak data demonstrated five ion peaks that identified subjects with NAFLD with an accuracy of 90% (-2 log likelihood 0.172; Wilks' Lambda 0.145 (p , 0.0001)). Further analysis revealed that breath isoprene (cholesterol synthesis), acetone (glucose metabolism), trimethyamine (choline metabolism by microbiota), acetaldehyde (ethanol metabolism), and pentane (oxidative stress) were significantly higher in the NAFLD group compared to normal liver group, p value, 0.05 for all (Table). Conclusion: Exhaled breath analysis is a promising noninvasive method to detect fatty liver in obese children. Isoprene, acetone, trimethylamine, acetaldehyde, and pentane are novel biomarkers that may help to gain insight into pathophysiological processes and pathways leading to the development of NAFLD. Future studies are needed to validate our findings.

Comparison of NCHS, CDC, and WHO curves in children with cardiovascular risk

ObjectiveThe study aimed to compare the prevalence of overweight and obesity according to three growth curves, created by the World Health Organization (WHO/2006), by the National Center for Health Statistics (NCHS/1977), and by the Centers for Disease Control and Prevention (CDC/2000) in children with cardiovascular risk factors. MethodsData from 118 children and adolescents, aged between 2 and 19 years, treated between the years 2001 to 2009 at the Pediatric Preventive Cardiology Outpatient Clinic of the Instituto de Cardiologia de Porto Alegre were evaluated. The variables analyzed were: weight, height, age, and gender. Variables were classified according to the following criteria: weight/age, height/age, and body mass index (BMI). The cutoff points used were obtained from the three growth curves: WHO/2006, NCHS/1977, and CDC/2000. ResultsRegarding the criterion weight/age by the NCHS curve, 18% of the children were classified as having normal weight, and 82% had excess weight; by the CDC curve, 28% had normal and 72% had excess weight; by the WHO curve, 16.0% had normal weight and 84% had excess weight. According to the BMI, 0.8% of the population was underweight. 7.6% and 6.8% had normal weight; 26.3% and 11.9% were overweight; and 65.3% and 80.5% were obese, according to the CDC and WHO curves, respectively. Regarding the height/age criterion, there was no significant difference between the references and, on average, 98.3% of the population showed adequate height for age. ConclusionThe new WHO curves are more sensitive to identify obesity in a population at risk, which has important implications for preventive and therapeutic management.

Feasibility of very-high resolution ultrasound to assess elastic and muscular arterial wall morphology in adolescents attending an outpatient clinic for obesity and lipid abnormalities

ObjectiveAtherosclerosis begins during early life and is accelerated in individuals with cardiovascular risk factors. We hypothesized that very-high resolution ultrasound (VHRU, 25–55MHz) could feasibly detect early arterial changes in adolescents with risk factors. MethodsWe prospectively imaged the carotid, brachial and radial arterial morphology (far wall intima–media thickness, IMT; adventitia thickness, AT) by VHRU in 58 youths (age 14±2 years) attending a Pediatric Preventive Cardiology Clinic for assessment and management of cardiovascular risk factors and compared the findings to those from an age-matched group of 67 controls. ResultsBrachial and radial imaging was successful for all subjects. The carotid far wall could not be imaged in 7% of the patients due to limitations in penetration. VHRU image quality was related to body size and imaging depth. Imaging and analysis time were 12±3 and 18±3min, respectively. Carotid IMT was increased in patients (0.42±0.05 vs. 0.40±0.06mm, p=0.05). No differences were found in brachial or radial IMT or AT vs. controls. Age, male gender, body mass index, systolic blood pressure (BP), but not lipid levels, were associated with arterial IMT in regression analyses. ConclusionVHRU is feasible in imaging carotid and peripheral muscular artery IMT in adolescents. The arterial IMT is associated with age, gender, adiposity and systolic BP, but not lipid levels, in this adolescent population. Further studies including patients with manifest clinical atherosclerosis are needed to assess if VHRU has applications in atherosclerosis research.

Hypertriglyceridemia in a Pediatric Referral Practice: Experience With 300 Patients

Pediatric hypertriglyceridemia is an emerging comorbidity of childhood obesity. This study reviewed medical records retrospectively to describe the characteristics and clinical course of 300 at-risk children followed in a pediatric preventive cardiology clinic. Average baseline triglyceride (TG) level was 269 mg/dL (SD 342 mg/dL); 91% had TG levels between 150 and 399 mg/dL. A total of 77% were overweight/obese, 23% had elevated blood pressure, 23% had a family history of high triglycerides, and 11% reported a psychiatric diagnosis (33.3% of those with severe TG elevations). Diet and activity change were the first-line therapies; few were taking lipid-lowering medications (baseline, 5.1%; follow-up, 11.4%). TG levels declined by 23% (average, 88 mg/dL; SD 231), often with a decline or plateau in TG risk category. Children with a lower body mass index (<85% gender- and age-matched percentile) were more likely to improve in TG category than heavier children (70% vs 40%; P ≤ .05).

A method for preventive cardiology in children

There are clear indications for prevention of atherosclerotic disease to begin in childhood. Optimal primary prevention will utilize a public health strategy. For children with elevated risk for atherosclerotic disease a clinically based prevention program is helpful. The indications for and an approach to the pediatric preventive cardiology clinic are reviewed.