American Heart Association guidelines for primary prevention of atherosclerotic cardiovascular disease beginning in childhood.

Atherosclerotic 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 29to 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 6to 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