Download Primary Prevention of Cardiovascular Disease

American Heart Association Guidelines for Primary Prevention of
Atherosclerotic Cardiovascular Disease Beginning in Childhood
Rae-Ellen W. Kavey, Stephen R. Daniels, Ronald M. Lauer, Dianne L. Atkins, Laura
L. Hayman and Kathryn Taubert
Circulation 2003;107;1562-1566
DOI: 10.1161/01.CIR.0000061521.15730.6E
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AHA Scientific Statement
American Heart Association Guidelines for Primary
Prevention of Atherosclerotic Cardiovascular Disease
Beginning in Childhood
Rae-Ellen W. Kavey, MD; Stephen R. Daniels, MD, PhD; Ronald M. Lauer, MD;
Dianne L. Atkins, MD; Laura L. Hayman, PhD, RN; Kathryn Taubert, PhD
A
therosclerotic cardiovascular disease remains the leading cause of both death and disability in North America.
Evidence that most cardiovascular disease is preventable led
to development of the American Heart Association’s initial
“Guide to the Primary Prevention of Cardiovascular Disease”
in 1996 and the updated version in 2002. Those guidelines do
not address prevention in children, a group for whom primary
prevention should hold the most promise. Emergence of
multiple lines of evidence with regard to the importance of
known risk factors for atherosclerotic disease in children and
young adults has provided the impetus to develop guidelines
for primary prevention in this young population.
Pathological studies have shown that both the presence and
extent of atherosclerotic lesions at autopsy after unexpected
death of children and young adults correlate positively and
significantly with established risk factors, namely lowdensity lipoprotein cholesterol, triglycerides, systolic and
diastolic blood pressure, body mass index, and presence of
cigarette smoking. Findings from the Bogalusa study indicate
that as the number of cardiovascular risk factors increases, so
does the pathological evidence for atherosclerosis in the aorta
and coronary arteries beginning in early childhood. Electron
beam computed tomography of coronary artery calcium and
increased carotid artery intima-media thickness, an ultrasound measure of carotid artery atherosclerosis, have been
evaluated in 29- to 39-year-olds monitored from 4 years of
age. Significant risk predictors for coronary artery calcium
were obesity and elevated blood pressure in childhood and
increased body mass index and dyslipidemia as young adults.
Multiple epidemiological studies have demonstrated a disturbing increase in the prevalence of obesity beginning in
childhood, with at least 22% of 6- to 17-year-olds diagnosed
as overweight. This is a cause for particular concern because
of the strong association between obesity and hypertension,
dyslipidemia, and type II diabetes mellitus beginning in
childhood. Long-term follow-up studies have demonstrated
tracking of obesity, hypercholesterolemia, and hypertension
from childhood into adult life. There is now substantial
scientific evidence documenting the acquisition of behaviors
associated with risk factors in childhood; these include
dietary habits, physical activity behaviors, and the use of
tobacco. Finally, an increasing body of research now documents the safety and success of intervention to reduce risk
factors in childhood. These studies include the Dietary
Intervention Study in Children trial, which demonstrated the
safety and efficacy of a low-fat diet in children with hypercholesterolemia; skill-training programs in smoking prevention in adolescents; the Child and Adolescent Trial for
Cardiovascular Health Study, which increased physical activity levels in children by using elementary school– based
programs; and other successful long-term family-based treatment programs for childhood obesity.
There has not been nor will likely ever be a controlled trial
comparing the effect of risk reductions beginning in childhood on the subsequent development of atherosclerotic disease. The existing evidence indicates that primary prevention
of atherosclerotic disease should begin in childhood. The
following guidelines represent a practical approach to cardiovascular health promotion and identification and management
of known risk factors for cardiovascular disease in children
and young adults. These guidelines complement other American Heart Association guidelines and should be useful for
primary care providers, specialists, and parents of children
and adolescents. The writing group that developed this
statement considered the National Cholesterol Education
Program Pediatric Panel Report, the second Task Force report
on the diagnosis and management of hypertension in childhood, the update of that task force report by the National High
Blood Pressure Education Program, and multiple additional
publications, which are included in the reading list. Two
The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside
relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required
to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.
This statement has been co-published in the April 2003 issue of The Journal of Pediatrics.
This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on November 4, 2002. A single reprint
is available by calling 800-242-8721 (US only) or writing the American Heart Association, Public Information, 7272 Greenville Ave, Dallas, TX
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(Circulation. 2003;107:1562-1566.)
© 2003 American Heart Association, Inc.
Circulation is available at http://www.circulationaha.org
DOI: 10.1161/01.CIR.0000061521.15730.6E
1562
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Kavey et al
TABLE 1.
Primary Prevention in Childhood
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Guidelines for Cardiovascular Health Promotion in All Children and Adolescents
Health Promotion Goals
Recommendations
Diet
●
●
●
●
● Assess diet at every visit.
● Match energy intake with energy needs for normal growth and development.
● Make appropriate changes to maintain a healthy weight and achieve weight loss when
indicated.
● Advocate consumption of a variety of fruits, vegetables, whole grains, dairy products,
fish, legumes, poultry, and lean meat.
● Fat intake is unrestricted prior to 2 years of age. After age 2, limit foods high in
saturated fats (⬍10% of calories per day), cholesterol (⬍300 mg per day), and
trans-fatty acids.
● Limit salt intake to ⬍6 g per day.
● Limit intake of sugar.
An overall healthy eating pattern
Appropriate body weight
Desirable lipid profile
Desirable blood pressure
Smoking
● No new initiation of cigarette smoking
● No exposure to environmental tobacco smoke
● Complete cessation for those who smoke
● Question tobacco use by parents at every visit.
● Question tobacco use by children at every visit starting at age 10.
● Provide clear, strong, informed, and personalized counseling against initiation of
smoking.
● Advise avoidance of second-hand smoke at home, with friends, at school, or at work.
Physical Activity
● Be physically active every day
● Reduce sedentary time (eg, television watching, computer,
video games, or time on the phone)
● Assess physical activity at every visit.
● Advise young people to participate in at least 60 minutes of moderate to vigorous
physical activity every day.
● Physical activity should be fun for children and adolescents.
● For adolescents, resistance training (10 to 15 repetitions at moderate intensity) can be
combined with aerobic activity in an overall activity program.
● Sedentary time should be limited. For example, limit television time to at most 2 hours
per day.
major primary prevention strategies for children and adolescents are outlined in the tables below: (1) Population guidelines are directed cardiovascular health promotion for the
entire pediatric population, whereas (2) individual guidelines
focus on the identification and management of children and
adolescents at highest risk for atherosclerotic disease.
The population guidelines, which apply to all children and
adolescents, are presented in Table 1. In this table, the goals
are presented in the left column and the recommendations for
achieving those goals are presented in the right. Table 2
presents general and risk factor–specific guidelines for identifying pediatric patients at high risk of future cardiovascular
disease. Finally, Table 3 presents goals and recommendations
to achieve the goals of reducing risks in children and
adolescents identified at high risk of future cardiovascular
disease.
These guidelines present a conservative approach in an
easy-to-use format identifying risk factors in childhood and
safely modifying those identified without harm to the growing child. The American Heart Association’s Council on
Cardiovascular Disease in the Young has developed a cardiovascular health schedule that allows risk factor identification and modification within the framework of routine pediatric care, and this approach is highly recommended
(Williams et al, reference 7 in section VI). These guidelines
are complementary to the recommendations published by
Williams et al. Risk reduction has been shown to delay the
onset and modify the course of atherosclerotic disease in
adults; with evidence for the extent and importance of
identified risk factors in the young, the time for primary
prevention beginning in childhood has come.
Selected Readings by Subject
I. Pathological Evidence for Risk Factor Impact in
the Young
1. Relationship of atherosclerosis in young men to serum lipoprotein
cholesterol concentrations and smoking: a preliminary report from
the Pathobiological Determinants of Atherosclerosis in Youth
(PDAY) Research Group. JAMA. 1990;264:3018 –3024.
2. McGill HC Jr, McMahan CA, Zieske AW, et al. Effects of nonlipid
risk factors on atherosclerosis in youth with a favorable lipoprotein
profile. Circulation. 2001;103:1546 –1550.
3. Newman WP 3rd, Freedman DS, Voors AW, et al. Relation of
serum lipoprotein levels and systolic blood pressure to early
atherosclerosis: the Bogalusa Heart Study. N Engl J Med.
1986;314:138 –144.
4. Berenson GS, Srinivasan SR, Bao W, et al. Association between
multiple cardiovascular risk factors and atherosclerosis in children
and young adults: the Bogalusa Heart Study. N Engl J Med.
1998;338:1650 –1656.
5. Mahoney LT, Burns TL, Stanford W, et al. Coronary risk factors
measured in childhood and young adult life are associated with
coronary artery calcification in young adults: the Muscatine Study.
J Am Coll Cardiol. 1996;27:277–284.
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TABLE 2.
Guidelines for Identification of Children and Adolescents at High Risk of CVD
Assessment
Recommendations
General Assessment
Goals for Pediatric Care Providers
● Timed, targeted risk factor assessment
● Appropriate interpretation of results and communication to
families
Goals for Parents
● Recognition of risk factor significance for development of
cardiovascular disease, especially family history
● Family history: Update regularly (parents, grandparents, aunts, and uncles)
with regard to obesity, hypertension, dyslipidemia, diabetes, cigarette
smoking, and cardiovascular disease before age 55 for men and age 65
for women.
● Height, weight, BMI: Assess at every examination.
● Blood pressure: Measure at every examination after age 3 years; chart for
age/sex/height.
● Diet and physical activity: Assess at every visit.
● Cigarette smoking: Evaluate starting at 9 to 10 years of age.
Specific Risk Assessment: Levels of Concern
Lipids and Lipoprotein
● Total cholesterol ⬎170 mg/dL is borderline; ⬎200 mg/dL
is elevated
● LDL-C ⬎110 mg/dL is borderline; ⬎130 mg/dL is elevated
● Triglycerides ⬎150 mg/dL
● HDL-C ⬍35 mg/dL
● Perform targeted screening of fasting lipids in children ⬎2 years of age
with a family history of dyslipidemia or premature CVD.
● For children in whom family history is unknown and other risk factors are
present, assess lipids and lipoproteins.
● If averaged results of 3 fasting lipid profiles are above cut points, refer to
Table 3.
Blood Pressure
● Systolic and diastolic blood pressure ⬎90th percentile for
age, sex, and height
● Know appropriate blood pressure measurement techniques, including
appropriate cuff size.
● Interpret blood pressure measurements on the basis of age, sex, and
height. (Blood pressure percentiles are available at
http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.htm.)
Body Size
● BMI ⬎85th percentile is at risk of overweight; ⬎95th
percentile is overweight
● Body size should be charted by BMI. (Norms for BMI percentiles are
available at http://www.cdc.gov/growthcharts/.)
● The 95th percentile can be approximated by the age (in years) ⫹13 for
boys and the age (in years) ⫹14 for girls after age 9 years.
BMI indicates body mass index; CVD, cardiovascular disease; HDL-C, high-density lipoprotein cholesterol; and LDL-C, low-density lipoprotein cholesterol.
II. Prevalence of Obesity/Type 2 Diabetes Mellitus
1. Luepker RV, Jacobs DR, Prineas RJ, et al. Secular trends of blood
pressure and body size in a multi-ethnic adolescent population:
1986 to 1996. J Pediatr. 1999;134:668 – 674.
2. Morrison JA, James FW, Sprecher DL, et al. Sex and race
differences in cardiovascular disease risk factor changes in schoolchildren, 1975–1990: the Princeton School Study. Am J Public
Health. 1999;89:1708 –1714.
3. Troiano RP, Flegal KM, Kuczmarski RJ, et al. Overweight
prevalence and trends for children and adolescents: the National
Health and Nutrition Examination Surveys, 1963 to 1991. Arch
Pediatr Adolesc Med. 1995;149:1085–1091.
4. Pinhas-Hamiel O, Dolan LM, Daniels SR, et al. Increased incidence of non-insulin-dependent diabetes mellitus among adolescents. J Pediatr. 1996;128(5 Pt 1):608 – 615.
5. Fagot-Campagna A, Pettitt DJ, Engelgau MM, et al. Type 2
diabetes among North American children and adolescents: an
epidemiologic review and a public health perspective. J Pediatr.
2000;136:664 – 672.
III. Tracking of Risk Factors From Childhood
Into Adult Life
1. Lauer RM, Lee J, Clarke WR. Factors affecting the relationship
between childhood and adult cholesterol level: the Muscatine
Study. Pediatrics. 1988;82:309 –318.
2. Lauer RM, Clarke WR. Childhood risk factors for high adult blood
pressure: the Muscatine Study. Pediatrics. 1989;84;633– 641.
3. Whitaker RC, Wright JA, Pepe MS, et al. Predicting obesity in
young adulthood from childhood and parental obesity. N Engl
J Med. 1997;337:869 – 873.
IV. Acquisition of Risk Behaviors in Childhood
1. Oliveria SA, Ellison RC, Moore LL, et al. Parent-child relationships in
nutrient intake: the Framingham Children’s Study. Am J Clin Nutr.
1992;56:593–598.
2. Feunekes GI, de Graaf C, Meyboom S, et al. Food choice and fat
intake of adolescents and adults: associations of intakes within
social networks. Prev Med. 1998;27(5 Pt 1):645– 656.
3. Janz KF, Dawson JD, Mahoney LT. Tracking physical fitness and
physical activity from childhood to adolescence: the Muscatine
study. Med Sci Sports Exerc. 2000;32:1250 –1257.
4. Powell KE, Dysinger W. Childhood participation in organized
school sports and physical education as precursors of adult physical
activity. Am J Prev Med. 1987;3:276 –281.
5. Rojas NL, Killen JD, Haydel KF, et al. Nicotine dependence
among adolescent smokers. Arch Pediatr Adolesc Med.
1998;152:151–156.
V. Intervention Trials
1. Obarzanek E, Kimm SY, Barton BA, et al. Long-term safety and
efficacy of a cholesterol-lowering diet in children with elevated
low-density lipoprotein cholesterol: seven-year results of the Dietary Intervention Study in Children (DISC). Pediatrics.
2001;107:256 –264.
2. Flynn BS, Warden JK, Secker-Walker R. Cigarette smoking
prevention: effects of mass media and school interventions targeted
to gender and age groups. J Health Educ. 1995;26:545–551.
3. Luepker RV, Perry CL, McKinlay SM, et al. Outcomes of a field
trial to improve children’s dietary patterns and physical activity:
the Child and Adolescent Trial for Cardiovascular Health. CATCH
collaborative group. JAMA. 1996;275:768 –776.
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TABLE 3.
Primary Prevention in Childhood
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Guidelines for Cardiovascular Risk Reduction: Intervention for Children and Adolescents With Identified Risk
Risk Intervention
Recommendations
Blood Cholesterol Management
GOALS:
● LDL-C ⬍160 mg/dL (⬍130 mg/dL is even better)
● For patients with diabetes, LDL-C ⬍100 mg/dL
● If LDL-C is above goals, initiate additional therapeutic lifestyle changes, including diet (⬍7%
of calories from saturated fat; ⬍200 mg cholesterol per day), in conjunction with a trained
dietitian.
● Consider LDL-lowering dietary options (increase soluble fiber by using age 关in years兴 plus 5
to 10 g up to age 15, when the total remains at 25 g per day) in conjunction with a trained
dietitian.
● Emphasize weight management and increased physical activity.
● If LDL-C is persistently above goals, evaluate for secondary causes (thyroid-stimulating
hormone, liver function tests, renal function tests, urinalysis).
● Consider pharmacological therapy for individuals with LDL ⬎190 mg/dL with no other risk
factors for CVD; or ⬎160 mg/dL with other risk factors present (blood pressure elevation,
diabetes, obesity, strong family history of premature CVD).
● Bile acid–binding resins or statins are usual first-line agents.
● Pharmacological intervention for dyslipidemia should be accomplished in collaboration with a
physician experienced in treatment of disorders of cholesterol in pediatric patients.
Other Lipids and Lipoprotein
● Elevated fasting TG and reduced HDL-C are often seen in the context of overweight with
insulin resistance. Therapeutic lifestyle change should include weight management with
appropriate energy intake and expenditure. Decrease intake of simple sugars.
● If fasting TG are persistently elevated, evaluate for secondary causes such as diabetes,
thyroid disease, renal disease, and alcohol abuse.
● No pharmacological interventions are recommended in children for isolated elevation of
fasting TG unless this is very marked (treatment may be initiated at TG ⬎400 mg/dL to
protect against postprandial TG of 1000 mg/dL or greater, which may be associated with an
increased risk of pancreatitis).
GOALS:
● Fasting TG ⬍150 mg/dL
● HDL-C ⬎35 mg/dL
Management of Blood Pressure Elevation
GOAL:
● Systolic and diastolic blood pressure ⬍95th percentile
for age, sex, and height
● Promote achievement of appropriate weight.
● Reduce sodium in the diet. Emphasize increased consumption of fruits and vegetables.
● If blood pressure is persistently above the 95th percentile, consider possible secondary
causes (eg, renal disease, coarctation of the aorta).
● Consider pharmacological therapy for individuals above the 95th percentile if lifestyle
modification brings no improvement and there is evidence of target organ changes (left
ventricular hypertrophy, microalbuminuria, retinal vascular abnormalities). Start blood pressure
medication individualized to other patient requirements and characteristics (ie, age, race,
need for drugs with specific benefits).
● Pharmacological management of hypertension should be accomplished in collaboration with a
physician experienced in pediatric hypertension.
Weight Management
GOAL:
● Achieve and maintain BMI ⬍95th percentile for age
and sex
● For children who are at risk of overweight (⬎85th percentile) or obesity (⬎95th percentile), a
weight management program should be initiated with appropriate energy balance achieved
through changes in diet and physical activity.
● For children of normal height, a secondary cause of obesity is unlikely.
● Weight management should be directed at all family members who are overweight, using a
family-centered, behavioral management approach.
● Weight management should be done in collaboration with a trained dietitian.
Diabetes Management
GOALS:
● Near normal fasting plasma glucose (⬍120 mg/dL)
● Near normal HgA1c (⬍7%) (goals for fasting glucose
and HgA1c should take into consideration age and risk
of hypoglycemia)
● Management of type 1 and type 2 diabetes in children and adolescents should be
accomplished in collaboration with a pediatric endocrinologist.
● For type 2 diabetes, the first step is weight management with improved diet and exercise.
● Because of risk for accelerated vascular disease, other risk factors (eg, blood pressure, lipid
abnormalities) should be treated more aggressively in patients with diabetes.
Cigarette Smoking Cessation
GOAL:
● Complete cessation of smoking for children and parents
who smoke
● Advise every tobacco user (parents and children) to quit and be prepared to provide
assistance with this (counseling/referral to develop a plan for quitting using available
community resources to help with smoking cessation).
TG indicates triglycerides.
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4. Sallis JF, McKenzie TL, Alcaraz JE, et al. The effects of a 2-year
physical education program (SPARK) on physical activity and
fitness in elementary school students. Sports, Play and Active
Recreation for Kids. Am J Public Health. 1997;87:1328 –1334.
4.
5.
VI. Pediatric Consensus Statements
1. American Academy of Pediatrics. National Cholesterol Education
Program: Report of the Expert Panel on Blood Cholesterol Levels in
Children and Adolescents. Pediatrics. 1992;89(3 Pt 2):525–584.
2. National High Blood Pressure Education Program Working Group
on Hypertension Control in Children and Adolescents. Update on
the 1987 Task Force Report on High Blood Pressure in Children
and Adolescents: a working group report from the National High
Blood Pressure Education Program. Pediatrics. 1996;98(4 Pt
1):649 – 658.
3. Barlow SE, Dietz WH. Obesity evaluation and treatment: Expert
Committee recommendations. The Maternal and Child Health Bureau,
6.
7.
Health Resources and Services Administration and the Department of
Health and Human Services. Pediatrics. 1998;102:E29.
American Diabetes Association. Type 2 diabetes in children and
adolescents. Diabetes Care. 2000;23:381–389.
American Academy of Pediatrics, Committee on Public Education.
Media education. Pediatrics. 1999;104(2 Pt 1):341–343.
Cavill N, Biddle S, Sallis JF. Health enhancing physical activity for
young people: statement of the United Kingdom expert consensus
conference. Pediatr Exerc Sci. 2001;13:12–25.
Williams CL, Hayman LL, Daniels SR, et al. Cardiovascular health in
childhood: a statement for health professionals from the Committee on
Atherosclerosis, Hypertension, and Obesity in the Young (AHOY) of
the Council on Cardiovascular Disease in the Young, American Heart
Association. Circulation. 2002;106:143–160. [Erratum Circulation.
2002;106:1178.]
KEY WORDS: AHA Scientific Statements
䡲 cardiovascular diseases 䡲 prevention
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䡲
pediatrics
䡲
atherosclerosis