Preventive Cardiology

Screening for Lipid Disorders

Goals of the new guidelines

• Identify familial hyperlipidemias (FH) associated with early cardiovascular disease, which are present in 1 in 300-500 children, but are asymptomatic until there is myocardial ischemia. Individuals with FH who are untreated have a risk of premature coronary heart disease 20 times greater than those without FH. (Of note, one study suggests the risk of cardiac events in FH can be reduced to that of the general adult population by statin therapy, but only if these lipid disorders are identified early.)
• Diagnose non-genetic LDL lipid disorders that require lifestyle modification. NHANES data suggest 1 in 5 adolescents in the US has some type of lipid disorder (JAMA 2010, MMWR Morb Mortal Wkly Rep. 2010 Jan 22:59(2):29-33. Prevalence of abnormal lipid levels among youths. United States, 1999-2006. Centers for Disease Control and Prevention [CDC)].)

Screening guidelines

• Screen all children once between the ages 9 and 11 years, and again once between 17 and 21 years.
• Continue selective screening of high risk patients (family history of early CVD events or other CVD risk factors) starting at age 2 years.
• Screen with a fasting lipid profile OR non-fasting TC and HDL to calculate non-HDL cholesterol levels.

Management guidelines

• If non-fasting non-HDL cholesterol is ≥ 145 mg/dL, or HDL < 40 mg/dL, obtain fasting lipid profile.
• Refer to specialist directly for LDL ≥ 250 mg/dL or fasting TG≥ 500 mg/dL.
• Initial treatment for nearly all patients is 6 months of targeted lifestyle change.
• Treat high TG differently from high LDL, both in terms of nutrition counseling and pharmacotherapy (guidelines include useful tables and algorithms to guide treatment).
• Use lipid-lowering medications only in patients who have not responded to 6 months of lifestyle counseling and have LDL ≥190 mg/dL.
• Use somewhat lower LDL cutpoints for patients with high-risk conditions using lower cutpoints.
• Recommended age for pharmacotherapy is ≥ 10 years, except in very high risk cases.
• Once LDL is optimized, high non-HDL cholesterol may be targeted to reduce residual CVD risk.

Controversy

Will these guidelines lead to an avalanche of statin prescriptions for children?
This fear is probably unfounded, based on the low prevalence of extremely elevated LDL and the fact that the recommendations are similar to those recommended by the AAP 2008 Statement on Cholesterol. The focus is on lifestyle modification for the first 6 months in nearly all patients, and continued lifestyle modification in all but extreme lipid disorders or high risk clinical conditions.

The number of children expected to require pharmacotherapy is likely to be small, around 1% of the population. Much of the initial management of identified CVD risk factors can be done in a primary care setting, if nutrition support and lifestyle counseling are available. In fact, these guidelines recommend emphasize initiation of lipid lowering medications in patients meeting criteria at age 10 years, whereas the AAP 2008 statement put more emphasis on age 8 years. For the few patients who need them, published data support our clinical experience that in the short and medium term, lipid-lowering medications are well tolerated and safe.