PEDIATRIC CARDIOLOGY CASES

1. Paediatric Cardiology
Case Scenarios
Murtaza Kamal
1

2. Scenario:07
2

3. • 12y, student class 7th
• Sedentary life:
• Online classes in COVID period
• TV addict
• No outdoor games
• Fast and junk food
• BMI: 31 kg/m2
• No family h/o SCD, HT, DM
The scenario…
3

4. Overweight and obesity: Definition
4

5. How commonly do you encounter obesity in
your office practice?
5

6. Why should we spare the genetics?…
6

7. Genetics is not confined to syndromes only…
• Mutations in genes encoding proteins
regulating appetite + metabolism
• Leptin- melanocortin pathway:
• Hunger+ energy homeostasis->
Mutation—> Hyperphagia+obesity
7

8. Long term CV risk
• Direct relationship with SBP, DBP, TGs levels
• Inverse relation with HDL
• Obesity related HT and metabolic syndrome:
– Insulin resistance
– Na retention
– Increased sympathetic nervous activity
– RAAS activation
– Altered vascular function
8

9. How do you tackle these obese children (in
terms of prevention+ treatment)?
9

10. Prevention+ management continued…
• Outdoor physical activities and games
• Good healthy eating habits:
• Avoid of junk/ fast foods
• Colour food plate
10

11. How commonly have you prescribed drugs for
obesity management in your patients?
• Sibutramine:
• Reduces food intake
• Attenuates fall in metabolic rate
• Orlistat:
• Reversible inhibitor of gastric+ pancreatic lipase
• Setmelanotide:
• Melanocortin 4 receptor agonist
11

12. Scenario:08
12

13. The scenario…
• 14 years old young active boy
• BMI: 26.5Kg/m2, BP: 116/76 mm hg
• Family h/o: Grandfather died at an age of 49 years
• Lipid profile:
• Cholesterol: 240mg/dl
• LDL: 180 mg/dl
• HDL: 32 mg/dl
• TGs: 172mg/dl
13

14. Future risk of CV morbidity
• Process of atherosclerosis begins in 1st decade
• Increase in cholesterol+ apolipoprotein levels in
childhood:
• Increase in cIMT
• Reduction in carotid elasticity
• Compromised brachial endothelial function
• Severity: Number+ intensity of risk factors
• Most powerful tool: Early detection of CV risk in
childhood
14

15. Future risk of CV morbidity
• LDL-C: Most implicated
• Continuous exposure to high serum LDL-C during
adolescence
• -> Accumulation of calcium in coronary
arteries
• -> Development of atherosclerotic
plaques
• Hypercholesterolemia: Most relevant CV risk
factor linked to progression of CAD
15

16. How often do you come across children with
hyperlipidemia in your office?
Limited information
Jaipur: 237 school children(13–17 years)
Borderline hypercholesterolemia (170–199 mg/dl): 33%
Definite hypercholesterolemia: 6.8%
Gupta et al. 1236 adolescents and young adults: M & F respectively:
High total cholesterol: 14% and 15%
High LDL cholesterol: 12% and 13%
High triglycerides: 14% and 16%
Low HDL cholesterol: 5%
16

17. How much to target for then?
17

18. When & whom to screen?
• AAP: Serum levels of cholesterol (total, LDL-C
and HDL-C)+ TGs in all children at 10 + 19 years
• Non-invasive methods for risk stratification:
cIMT+ LV morphology, to prevent future
development of CVD
18

19. How do you tackle these children (in terms of
prevention+ treatment)?
• Diagnose hypercholesterolemia and start
early targeted treatment
• First line:
• Behavioural intervention
• Lifestyle modification
• Eating habits
19

20. How frequently do you prescribe statins to
these children?
• Safe in children and adolescents
• Treatment with low doses indicated in
children with heterozygous form of FH from
8-10 years
• —> Long term benefit
• —> Lower incidence of atherosclerotic
CVD in 40 years follow up
20

21. CV risk in children: A burden for future generations
21

22. 22

23. Take home message
• CVD: Rapidly increasing cause of morbidity + mortality
• Early atherosclerosis can be detected in childhood,
progression depends on exposure to several risk factors
• Start screening from end of 1st decade
• Low fruits+ vegetable consumption+ poor physical
activity: Rapid progression of arterial inflammation
• Adoption of preventive strategies since early life both in
general population and in a targeted way in subjects with
increased CV risk
23

24. 24