Managing Cardiometabolic Risk in the Younger Population

Las Vegas—Recent evidence indicates that cardiometabolic risk begins in childhood. Early identification, prevention, and treatment are key to slowing the epidemic of cardiometabolic syndrome in adults. Edward Shahady, MD, FAAFP, ABCL, addressed cardiometabolic risk in adolescents and young adults during a workshop at the CRS meeting.

Dr. Shahady, clinical professor of family medicine, University of Miami and University of Florida, opened the session by reviewing the National Heart, Lung and Blood Institute (NHLBI) lipid guidelines for children and adolescents and the controversy over the screening recommendations. In late 2011, the NHLBI released new guidelines that recommended universal screening for children 9 to 11 years of age with a nonfasting lipid panel and targeted screening of 30% to 40% of 2- to 8-year-old and 12- to 16-year-old children with 2 fasting lipid profiles. Previous guidelines suggested screening only high-risk children.

Despite endorsement by the American Academy of Pediatrics (AAP), the recommendations drew criticism. Dr. Shahady referenced an article that outlined the critics’ concerns, where they argued that the recommendations were made without consideration of benefit, harm, and cost [JAMA. 2012;308(8):750-751]. They also argued that the evidence used to justify such screening is not as strong as implied by the NHLBI and the recommendations are based heavily on expert opinion. They also expressed concern that many of the NHLBI panel members had conflicts of interest within the industry. In response, the NHLBI expert panel argued that atherosclerosis is a lifelong process that begins in childhood and not all high-risk children can be identified without lipid screening.

“Atherosclerosis begins in childhood, and a high [low-density lipoprotein (LDL)] level is associated with an increased level of atherosclerosis,” Dr. Shahady said. The NHLBI guidelines for managing dyslipidemia with statin therapy in children recommended:

• Initiate statin therapy if, after 6 months of lifestyle therapy, the lipid profile and current clinical status show the following:
    o LDL cholesterol ≥190 mg/dL
    o LDL cholesterol 160 mg/dL to 189 mg/dL and ≥1 of the following:
        - Family history of premature cardiovascular disease (CVD)
        - Diabetes or hypertension
        - LDL cholesterol ≥130 mg/dL to 159 mg/dL with CVD

He also analyzed familial hypercholesterolemia (FH) prevalence and treatment. FH are a group of genetic defects characterized by high cholesterol levels in the blood and increased risk of coronary heart disease (CHD). The prevalence of heterozygous FH is 1 in 200 to 500 individuals, and most individuals are not diagnosed until later in life, if at all. Furthermore, heterozygous FH is a frequent cause of CHD, according to the presentation.

Current guidelines recommend patients with heterozygous FH receive long-term therapy to reduce LDL cholesterol by 50%; this goal requires the use of a high-intensity statin. Further intensification of therapy is required for individuals with established CVD or CVD risk factors. Given the potential effects of long-term statin therapy on growth and development in children, Dr. Shahady referenced a study of 214 children with heterozygous FH who were 8 to 18 years of age [JAMA. 2004;292(3):331-337]. The researchers found that 2 years of pravastatin therapy induced a significant regression of carotid atherosclerosis with no adverse effects on growth, sexual maturation, hormone levels, or liver or muscle tissue.

Dr. Shahady concluded the session by discussing the evaluation and treatment of metabolic syndrome and type 2 diabetes in adolescents and young adults. “Metabolic syndrome is common in obese adolescents and young adults,” he said.

The development of nonalcoholic fatty liver disease (NAFLD) is strongly associated with metabolic syndrome. A significant majority of patients (90%) with NAFLD have >1 feature of metabolic syndrome, while 33% of patients have ≥3 criteria. NAFLD is associated with endothelial dysfunction and early atherosclerosis in children and adolescents, explained Dr. Shahady.

Many patients with metabolic syndrome characteristics face the risk of developing diabetes and premature CVD later in life. “Many adolescents and young adults proceed from prediabetes to type 2 diabetes,” he said, noting that young onset type 2 diabetes is more lethal than type 1 diabetes. Dr. Shahady reviewed the clinical practice guideline for managing type 2 diabetes in children and adolescents from the AAP [Pediatrics. 2013;131(12):364-382]:

• Patients presenting with glucose ≥250 mg/dL and glycated hemoglobin (HbA1c) ≥9% should be started on insulin at least initially
• In all others, lifestyle changes and metformin are the initial treatment of choice for individuals 10 to 18 years of age
• Goal of treatment is HbA1c <7%
• If goals are not met, add insulin

Currently, there are no other oral or injectable agents that are FDA-approved for children ≤18 years of age.—Eileen Koutnik-Fotopoulos