This document discusses atherosclerotic heart disease and cardiovascular risk factors in children. It notes that atherosclerosis develops over decades, with risk factors like high cholesterol beginning early in life. Studies found that fatty streak lesions can be present in coronary arteries by age 15, and high childhood cholesterol levels often predict high cholesterol as adults. The document recommends treating pediatric dyslipidemias with a multidisciplinary approach focusing on diet, lifestyle changes, and potentially pharmacotherapy to reduce future cardiovascular risks.

1. Lecturer :
dr. Lanny Christine Gultom, Sp.A
Created by :
Aditya Prabawa
(030.06.012)
Department of Child Health Fatmawati General Hospital
Faculty of Medicine Trisakti University
Jakarta, September 30, 2010

2. Atherosclerotic heart disease is a major cause of adult
morbidity and mortality in the United States
Atherosclerotic cardiovascular  multifactorial like
nutrition (total cholesterol), hypertension, obesity
Framingham Heart Study, Cohort study Reducing
cholesterol by 8% reduces the risk of CHD by 19%.
Pharmacotherapy  not ideal of treatment modality
Nutritional approaches are more advisable ways of
treating the cardiovascular risk factor in child and
adolesence.

3. Atherosclerosis usually takes decades to develop
Disease process itself and the nutritional habits that
propagate the disease begin early
The degree of progression early atherosclerosis by young
adulthood, related to increased non-HDL cholesterol
( LDL and VLDL ) and decreased HDL cholesterol
Fatty streak precursor lesions were present by age 15 years
in the coronary arteries of children.
From : Pathological Determinants of Atherosclerosis in
Youth (PDAY)

4. Population with higher rates of CHD have higher pediatric
population mean total cholesterol
Children with very high cholesterol levels are highly likely
to be adults with high cholesterol
Nearly half of subjects with high cholesterol as children
had high cholesterol levels as adults.
High total cholesterol values predicted greater risk of
CHD, mortality from CHD and overall mortality later in
adult life
From : cohorts study of Johns Hopkins University medical
students

5. Family History
Obesity
Hypertension
Heart transplant recipients
Kawasaki disease
Congenital heart disease like : coarctation and
transposition of the great arteries
Diabetes mellitus type 1 and type 2

6. Framingham Heart Study : half of who had
myocardial infarctions had normal cholesterol
levels
Pathophysiology : injury on vascular endothelial
and systemic inflammation
C-reactive protein (CRP), is proving to be a
valuable tool for assessing cardiovascular disease
risk in adults.
CRP is an acute-phase reactant.

9. High level of hsCRP in children that is ultimately
found to be associated with increased
cardiovascular risk
Profound hyperhomocysteinemia owing to the
rare genetic defect cystathionine-β-synthase
deficiency, folate deficiency, pyridoxine,
cobalamine deficiency have dramatic elevation in
thrombosis risk

12. Metabolic syndrome  collection of cardiovascular risk
factors associated with a higher rate of atherosclerotic
disease.
Hypertension,
Elevated fasting glucose levels,
Central obesity,
Low HDL and high triglycerides
Body Mass Index ( BMI ) above the 95th
percentile for age
in childhood is a risk factor for future metabolic syndrome

14. • Lipoprotein a is a variant LDL particle with a
covalently bound protein portion termed
apolipoprotein a
• High level are thought to be atherogenic because the
particle not only participates in atheromatous plaques
but also impairs fibrinolysis by preventing normal
plasminogen activation
• Involved in the trombosis cardiovascular disease

16. Lipid component :
Cholesterol
Triglycerida
FFA : saturated
unsaturated monounsaturated
polyunsaturated : cis, trans

17. Several types of lipoproteins, classified by density :
1. Chylomicrons
2. VLDL
3. LDL
4. HDL

24. History taking
Physical examination
Laboratory finding

26. Endocrine and metabolic state
• Diabetes mellitus
- Type I: with concomitant primary hyperlipidemia, very high
vascular risk
- Type II: particularly related to high triglycerides. Insulin
resistance states without overt diabetes
• Pregnancy
• Hypothyroidism
• Anorexia nervosa
Hepatic disease
• Hepatitis of any etiology
• Congenital biliary atresia
• Benign recurrent intrahepatic cholestasis

27. Renal disease
• Nephrotic syndrome
• Any renal inflammatory state
• Hemolytic uremic syndrome
Drugs and other agents
• Corticosteroids (systemic): primarily hypertriglyceridemia
• Thiazides
• Beta-blockers
• Oral contraceptives
• Antiepileptic medications
• Ethanol: low-dose, regular consumption increases salutary
HDL; in excess, hypertriglyceridemia.

29. Pediatric lipid treatment programs that employ a
multidisciplinary approach are more likely to
be successful
1. Dietary treatment is the first line of intervention
in all childhood dyslipidemias
2. Pharmacologic intervention
3. Education for lifestyle changes

30. • Step One : reduces total fat intake to less than 30% of total calories, with a goal of
saturated fat representing less than 10% of total calories and cholesterol intakes of
less than 300 mg/day.
• The Step Two diet restricts saturated fat intake to less than 7% of daily calories.
• Fiber supplementation
• Reduces carbohydrate intake
• STANOL-CONTAINING MARGARINES AND OMEGA-3 FATTY ACIDS
From : The NCEP has recommended a two-level nutritional approach, adopted with variations by the American Heart
Association and the American Academy of Pediatrics

32. Drug mechanism of action

34. • Pediatric lipid disorders contribute to future
cardiovascular
• Pediatric hyperlipidemias might be most safely, and
perhaps most effectively, treated with a
multidisciplinary approach.
• Future research should focus on longer-term
evaluation of antihyperlipidemic medications in
young patients and on developing markers of
preclinical disease that can be used to evaluate the
efficacy of interventions for atherosclerosis
prevention.

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36. THANK YOU