Cardiovascular Disease Screening Misses At-Risk Youth

Hypercholesterolemia, atherosclerosis, and coronary artery disease are ever-growing problems in our society. While these “adult” medical issues rarely concerned pediatricians in the past, it is now well recognized that these troublesome processes begin in childhood. In 2008, the American Academy of Pediatrics (AAP) called on pediatric providers to screen for high cholesterol levels in children and teens who had a family member with coronary artery disease before age 55 years; a parent with a history of hypercholesterolemia; an unknown family history; or risk factors, such as obesity and hypertension.¹ However, a recent study by Ritchie and colleagues² indicates that this selective screening may be missing affected children.

To determine how well the current screening guidelines identify children with hypercholesterolemia, Ritchie and colleagues² analyzed data from more than 20,000 children involved in the Coronary Artery Risk Detection in Appalachian Communities (CARDIAC) Project from September 2003 until April 2008. The CARDIAC Project has offered universal cholesterol screening to all fifth-grade students in public schools in West Virginia since 2000. The authors included children with a fasting lipid profile—consisting of total cholesterol, high-density lipoprotein (HDL) cholesterol, triglycerides, and low-density lipoprotein (LDL) cholesterol—and a completed family history questionnaire. They excluded children who had incomplete data.

Many youths who do not meet screening criteria have high LDL levels. Of the children whose data were analyzed, 71.4% would be screened based on the current guidelines. Of those, 8.3% had an LDL level of 130 mg/dL or higher, and 1.2% had an LDL level of 160 mg/dL or higher. Of the children who did not meet the screening criteria, 9.5% had an LDL of 130 mg/dL or higher, and 1.7% had an LDL level of 160 mg/dL or higher. The current AAP guidelines recommend pharmacologic therapy for children older than 8 years with risk factors, such as a positive family history or obesity, when LDL levels are persistently above 160 mg/dL, despite diet changes. For children without risk factors, pharmacologic treatment is recommended for persistent LDL levels above 190 mg/dL, with diet therapy. If pharmacologic therapy is considered for all children with an LDL level above 160 mg/dL, Ritchie and colleagues found that a third of these children would have been missed with the current screening guidelines. Those who do not require drug therapy may be in need of other treatment, such as close follow-up, lifestyle changes, and lipid evaluation of other family members.

The authors state that this study was conducted in a community where the prevalence of heart disease and childhood obesity, as well as uninsured person, is high. Many of the children’s parents and grandparents may be too young to have had problems detected yet, or may not have had testing with fasting lipid profiles. However, this is likely the case in many communities.

Encourage testing of family members of at-risk children. While universal cholesterol screening is a large undertaking, the Ritchie study indicates that it may be necessary in order to appropriately identify at-risk children and teens. If we can catch hypercholesterolemia at an early stage, and treat it with lifestyle changes and close follow-up, we may be able to prevent future problems from coronary artery disease and atherosclerosis. In the short term, we can encourage the family members of these children to be tested and treated, if necessary, before a catastrophic event occurs.