cardiovasular health-kavey (1)

8/17/2019 Cardiovasular Health-Kavey (1)

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New National Heart Lungand Blood Institute (NHLBI)Expert Panel Guidelines for

Cardiovascular Health andis! eduction in Childhood

Rae-Ellen W. Kavey, MD, MPH, FAAPProfessor of Pediatrics, Division of

Pediatric Cardiology Former H!"# Coordinator forCardiovasc$lar Ris% Red$ction inC&ild&ood 'olisano C&ildren(s Hos)ital

*niversity of Roc&ester Medical Center

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Prepared for your next patient.


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• Statements and opinions expressed are those of the authors andnot necessarily those of the American Academy of Pediatrics.

• Mead Johnson sponsors programs such as this to give healthcare

professionals access to scientic and educational informationprovided by experts. The presenter has complete andindependent control over the planning and content of thepresentation and is not receiving any compensation from Mead

Johnson for this presentation. The presenter!s comments andopinions are not necessarily those of Mead Johnson. #n the eventthat the presentation contains statements about uses of drugsthat are not $ithin the drugs% approved indications Mead

Johnson does not promote the use of any drug for indicationsoutside the &'A(approved product label.

"isclai#ers


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• )nderstand the complex and diverse evidence baseand the revie$ process that led to the *+,,recommendations.

• -e a$are of the ne$ evidence(based dietaryrecommendations for cardiovascular health.

• ecogni/e the guideline recommendations for lipidscreening and management in childhood.

• -e familiar $ith the format of the guidelines and ho$

to access ris0 factor 1&2(specic information to usein managing children and adolescents.

Learning $%&ectives


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• #ntroduction to the guidelines and evidencerevie$ process3grading system

• 4vervie$ of the report format56 State of the science

6 #ndividual & sections74vervie$ of the evidenceand graded recommendations for each ma8or ris0factor

6 Age( and &(specic integrated cardiovascular

19:2 health schedule• ;xamples5,29: health diet

*2


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#. &ormal evidence revie$ =radedrecommendations by an expert panel.

##. #ntegrated7multiple &s addressed in a singleguideline

###. &ormal )nited States 'epartment of >ealth and>uman Services 1>>S2 revie$ and approvalprocess

#:. outinely updated

NHLBI Guidelines New

*pproach


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• ;ndpoint of clinical cardiovascular disease19:'2 remote

• ?ide age range of sub8ects5 -irth to *, yearsof age

• Multiple &s to be addressed• ;pidemiologic studies7not 8ust randomi/ed

controlled trials 19Ts2 @ #mportant evidence• =oal5 Prevention of ris0 factors

Prevention of future disease5Primordial and primary prevention

• Ac0no$ledged gaps in the evidence base butrecommendations needed to guide patient care

Pediatric Guideline

Considerations


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• 12 family history for9:'

• #ncreasing age

• Male sex• -lood pressure 1-P23

hypertension•


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#nclude rationale for evaluation3intervention in childhood. #nclude selected observational3epidemiologic studies5

6 Cational >ealth and Cutrition ;xamination Survey 1C>AC;S26 -ogalusa >eart Study6 Muscatine Study6 -eaver 9ounty S26 9ardiovascular is0 in Doung &inns Study

Time frame5 ,EF,G*++FH ;nglish language PubMed3M;'


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#. 'ene critical uestions evidence gradingsystem.

##. ;lectronic search5 K,++++++ titles serial

revie$

L++ 9Ts3systematicrevie$s3meta(analyses *LF epidemiologicstudies abstracted into evidence tables

###. 'ene decision ma0ing process forrecommendations.

#:. evie$ and grade evidence.:. 'evelop age(specic recommendations integrated

across &s and $ithin regular pediatric care.

Guideline "evelop#ent

Process


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Grade Evidence

*?ell(designed 9Ts in a population similar to theguideline!s target population

B9Ts $ith minor limitationsH genetic natural historystudiesH over$helmingly consistent evidence fromobservational studies

C 4bservational studies 1case(control and cohort design2

";xpert opinion case reports or reasoning from rstprinciples 1bench research or animal studies2

American Academy of Pediatrics Steering 9ommittee on uality #mprovement. 9lassifying recommendations forguidelines. Pediatrics. *++LH,,L1N25FOLGFOO

Evidence Grading /0ste#


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/tate#ent "e.nition I#plication

Strongrecommendation

;vidence grade A or -

-enet clearly exceeds harmShould follo$

ecommendation ;vidence grade - or 9-enet exceeds harm butevidence is not as clear

Should generallyfollo$

4ptional

?ell(performed studies 1=radeA - 92 sho$ no clearadvantage or evidence issuspect 1=rade '2

&lexible responseincluding patient

preference

Corecommendation

;vidence lac0ing or balancebet$een benet and harm isunclear

#ndependentdecisionH needne$ evidence

/trength of

eco##endation


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:oting to be in support of or opposed to arecommendation5

• Agreement by QF+R Strong consensus presentedas such in the guidelines

• Agreement by +R ecommendation not includedin the guidelinesH ho$ever revie$ of the sub8ect couldbe included in the discussion for that & area

• Agreement by +RGF+R Moderate consensus in

support of the recommendationH this level ofagreement to be presented $ith that language in theguidelines and accompanied by discussion of the

conBicting issues

Expert Panel "ecision1

#a!ing Process


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/2*2E $ 2HE/CIENCE


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evie$ of the evidence lin0ing &s in childhood todevelopment and progression of atherosclerosis to

manifestclinical 9:'5

&rom autopsy and vascular imaging studies5Atherosclerosis begins in childhood.Atherosclerotic extent and progression correlate directly

$ith the number3severity of 0no$n &s.

&rom epidemiologic studies5&s are present from infancy and trac0 into adult life.is0 behaviors are acuired in childhood and persist into

adult life.


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• Bac!ground Summary of the epidemiologic evidencelin0ing the & in childhood to development of 9:'

• Evidence eview Process All 9Ts addressing & changerelative to measured outcomes included and graded $ithpre(identied criteria.

• ;vidence tables are available at http533$$$.nhlbi.nih.gov3guidelines3cvdUped3index.htm

• $verview 'ue to the large volume3diverse nature ofincluded studies critical overvie$ is provided in each &section highlighting the panel!s vie$ of the most important

evidence.• Conclusions ;vidence is summari/ed and graded age(

specic recommendations. ?here evidence is inadeuaterecommendations are a consensus of the expert panel.

Individual is! actor

/ections

http://www.nhlbi.nih.gov/guidelines/cvd_ped/index.htmhttp://www.nhlbi.nih.gov/guidelines/cvd_ped/index.htm


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IN"I,I"3*L I/4 *C2$ /EC2I$N/N32I2I$N *N" "IE2

v ence or on ro ng a n a e n oo


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Abbreviation5 ST#P Special Tur0u 9oronary is0 &actor #ntervention Pro8ect

Simell 4 Ciini0os0i > Vnnemaa T et al. ST#P Study =roup. 9ohort Prole5 The ST#P Study 1Special Tur0u9oronary is0 &actor #ntervention Pro8ect2 an #nfancy(onset 'ietary and


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• #ntervention 1#CT2 group counseled by dietitians to limitsaturated fat inta0e to X,+R total fat to N+R6NWR oftotal calories beginning at O months of age

• -reastfeeding encouraged as long as possible

• Transitioned from breastfeeding to s0im mil0• 9ontrol 194C2 group received no special dietaryguidance

•


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R ofenergy

OmY1-3


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/2IP /tud0 esults

#ntervention vs 9ontrol "IE25 Signicantly lo$er saturated fat3cholesterol inta0e from,N months to ,E years of age.

LIPI"/5 Signicantly lo$er lo$(density lipoprotein cholesterol1


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• 'ietary counseling begun in infancy iseZective $ith results sustained into youngadult life.

•


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• ST#P Study ndings and multiple other 9Ts in healthy normo( and hyper(cholesterolemic children 1O months to ,F years of age2 achieved anaverage total fat inta0e of *FR6N+R and saturated fat inta0e of FR6,+Rof calories.

•


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• Among children * to ,F years of age in the)S the average daily inta0e of energy fromadded sugars is NW 0cal.

• Sugar(s$eetened beverages 1sodaenergy3sports drin0s fruit drin0s2 are the top* sources of calories from added sugars in allage and demographic groups.

• Across beverage categories children * to ,Fyears of age consumed ,O, 0cal3day fromsugar(s$eetened beverages 1soda and fruitdrin0s combined2.

/ugar1/weetened

Beverages Bac!ground


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/ugar1/weetened

BeverageConsu#ption


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• &rom C>AC;S *++NG*++L nearly L+R of total caloriesconsumed by *( to ,F(year(olds in the )S $ere emptycalories.

• >alf of all empty calories come from specic foods5 soda

fruit drin0s dairy grain desserts and pi//a.• #n the C=>S sugar(s$eetened beverage consumption $assignicantly associated $ith higher daily calorie inta0e. Theaverage daily calorie inta0e increased by approximately F*calories for every ,++ grams of soda.

• A *++ systematic revie$ of sugar(s$eetened beverage

inta0e and $eight gain $ith *, studies in children andadolescents concluded that greater consumption of sugar(s$eetened beverages is signicantly associated $ith both$eight gain and obesity.Striegel(Moore > Thompson ' AZenito S= et al. 9orrelates of beverage inta0e in adolescent girls5 the

Cational >eart ealth Study. J Pediatr . *++H,LF1*25,W*G,WLH Mali0:S Schul/e M- >u &-. #nta0e of sugar(s$eetened beverages and $eight gain5 a systematic revie$. Am JClin Nutr . *++HFL1*25*OLG*FF

Evidence for ole of /ugar1

/weetenedBeverages in $%esit0Epide#iologic "ata


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• ,+N adolescents 1-M# K*Wth percentile2 randomi/ed• #CT5 &ree home delivery of non(caloric beverages for *W

$ee0s• 94C5 )sual beverage consumption• esults5

,2 9onsumption of sugar(s$eetened beverages decreased byF*R in #CT vs no change in 94C.

*2 9hange in -M#5 #CT5 +.+O+.,LH 94C5 +.*,+.,WN2 Among -M# top tertile change $as signicantly greater for

#CT1(+.N+.*N vs +.,*+.*2

• 9onclusion5 A 4sganian S] et al. ;Zects of decreasing sugar(s$eetened beverage

consumption on body $eight in adolescents5 a randomi/ed controlled pilot study. Pediatrics.*++H,,O1N25ONGF+

C2 Evidence egarding

/ugar1/weetened BeverageInta!e : 2rials


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• primary schools in south$est ;ngland5 LL children Oto ,, years of age

•;ducational program on nutrition focused oncarbonated drin0 consumption for , school year.

esults,2 N(day consumption of carbonated drin0s decreased by

+. glasses in #CT vs an increase of +.* glasses in 94C.

*2 At ,* months of age the percentage of over$eight andobese children decreased by a mean of +.*R in #CT vsan increase of O.WR in 94C.

James J Thomas P 9avan ' et al. Preventing childhood obesity by reducing consumption of carbonateddrin0s5 cluster randomised controlled trial. BMJ. *++LHN*F1OLW+25,*NO

Preventing Childhood $%esit0

%0 educing Consu#ption ofCar%onated "rin!s Cluster1ando#i6ed Controlled 2rial

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• Epide#iologic "ata Strong evidence that a higher consumption ofsugar(s$eetened beverages is associated $ith higher caloric inta0eand development of obesity.

• C2s #n small select populations 9Ts that limit sugar(s$eetenedbeverage consumption reduce development and3or progression of

obesity. ;vidence revie$ led to recommendation5


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*ge eco##endation Grade

-irthG months

#nfants should be exclusively breastfed 1no

supplemental formula or other foods2 until months of age.Y -

G,* months

9ontinue breastfeedingYY until at least ,*months of age $hile gradually adding solidsHtransition to iron(fortied formula until ,*months if reducing breastfeeding.

-

&at inta0e in infants X,* months of age shouldnot be restricted $ithout medical indication. '


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*geeco##endatio

nGrade

,*G*Lmonths

Transition to reduced(fat 1*R tofat free2 unBavored co$!s mil0. -ypertension 1'AS>2(type diet rich in fruitsvegetables $holegrains lo$(fat3fat(freemil0 and mil0 productsHlo$er in sugar.

Cardiovascular HealthIntegrated Lifest0le "iet (CHIL";) cont8

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*geeco##endati

onGrade

*G,+ yearsPrimary beverage5 fat(freeunBavored mil0 A


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*geeco##endati

onGrad

e,,6*,years

Primary beverage5 fat(freeunBavored mil0 A


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Gender*ge

(9ears) /edentar0

-oderatel0 *ctive *ctive

Child *GN ,+++G,*++ ,+++G,L++ ,+++G,L++

e#ale

LGFEG,N,LG,F,EGN+

,*++G,L++,L++G,++

,F++,F++G*+++

,L++G,++,++G*+++

*+++*+++G**++

,L++G,F++,F++G**++

*L++*L++

-ale

LGFEG,N,LG,F,EGN+

,*++G,L++,++G*+++*+++G*L++*L++G*++

,L++G,++,F++G**++*L++G*F++*++G*F++

,++G*+++*+++G*++*F++GN*++

N+++

Esti#ated Energ0 e


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"*/H Eating Plan /ervings per "a0 %0ood Group and EE

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"*/H Eatin Plan /er in s per "a % ood


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"*/H Eating Plan /ervings per "a0 %0 oodGroup and EE cont8

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I/4 *C2$ LIPI"/ *N"

LIP$P$2EIN//CEENING *N" -*N*GE-EN2

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• 9ondition is an important health problem.

• Catural history of the condition is $ell understood.

• 'etectable & or disease mar0er $ith established

norms.•


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• ;pidemiologic studies provide normative distributions for lipidlevels in children and adolescents. 1=rade -2

• Analysis of fasting lipid prole 1&'


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• Selective screening protocols identify less than halfof children $ith extreme hypercholesterolemia.(Grade B)

• #n hypercholesterolemic adults normali/ation of


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• Co 9T of screening in childhood treatment vs no treatment $ith follo$(up

to clinical disease proving that earlystage treatment is more eZective thantreatment at a later stage.

• Treatment trials in children are relatively

short in duration.

Evidence Li#ited+Lac!ing

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• Prior guidelines recommend targeted screening based on12 family history of premature 9:' 1M XWW years of ageH& XW years of age in expanded ,st degree pedigree2 ordyslipidemia 3( obesity.

• #n multiple studies NWRGLWR of children have beenfound to have 12 family history and up to NWR $ill havea -M# KFWth percentile.

• #n trials of universal screening =>?@A>? of children+adolescents with high cholesterol were not

identi.ed with targeted screen %ased on fa#il0 hx+1 o%esit08• #n addition family history is not reliable and is often

unavailable.

esults of 2argeted Cholesterol

/creening 3sing a#il0 Histor0and B-I

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• Con(>''


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*CCEP2*BLE

B$"ELINE

*BN$-*L

2C X,O+ ,O+6,EE K*++

L"L1C X,,+ ,,+6,*E K,N+

Non1H"L1C

X,*+ ,*+6,LL K,LW

2G

+6Ey5 XOW

,+6,Ey5XE+

OW6EE

E+6,*E

K,++

K,N+

H"L KLW L+6LW XL+

Plas#a Lipid "istri%ution

(#g+dL) for Children and*dolescents

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• Age(specic screening recommendations

• =raded treatment algorithms for diet and drug

treatment• ;vidence(based diet recommendations for children

$ith elevated


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• Co screening belo$ * years of age (GradeC+eco##end)

• *6,+ years5 Selective screening if5

,2&amily history 12 for early 9:'*2Parent $ith 0no$n dyslipidemia

N29hild $ith established &

L29hild $ith special ris0 condition

• ,+ years5 )niversal screening (Grade B+/trongl0reco##end) $ith non(fasting non(>'


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peco##endations %0 *ge

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Evidence1Based Lipid *ssess#ent


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eco##endations %0 *ge cont8

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High is!• 'iabetes mellitus Type , and Type *• 9hronic renal disease3end(stage renal

disease3postrenal transplant

• Post(orthotopic heart transplant• ]a$asa0i disease $ith current aneurysms

-oderate is!• ]a$asa0i disease $ith regressed coronary aneurysms• 9hronic inBammatory disease 1systemic lupus

erythematosus 8uvenile rheumatoid arthritis2• >uman immunodeciency virus infection• Cephrotic syndrome

/pecial is! Conditions

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"0slipide#ia *lgorith# 2*GE2 L"L1C


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FLP x 2, average results

LDL-C >130, 2!0 mg"dL* # $arget LDL-C$% >100, !00 mg"dL, 10y # $arget $%

>130, !00 mg"dL, 10&1'y ($% algorit)m

Exclude secondary causes.

Evaluate for other RFs.

Start CHILD 2-LDL diet

+ lifestyle modification for 6 months.

FLP

LDL-C >1'0 mg"dL→ +nitiate statin t)eray

LDL-C >10.1/' mg"dLFx ( or

1 )ig)-level F or

>2 moderate-level Fs

# +nitiate statin t)eray

$% >!00 mg"dL,

# Consult liid

seialist

LDL-C 130 mg"dL (4GOAL

# Continue C+LD 2-LDL diet5

→ eeat fasting liid rofile 6 12m5

LDL-C >2!0 mg"dL

# Consult liid

seialist

LDL-C >130.1/' mg"dLFx (-

7o ot)er Fs

→ Continue C+LD 2-LDL diet5

Follo8 6 m 8it) liid

rofile, Fx"F udate5

LDL-C >130.1!' mg"dL +2 )ig)-level Fs or

1 )ig)-level + >2 moderate-level

Fs or linial C9D

# +nitiate statin t)eray

Follo8 8it) FLPs, related )emistries5


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→ LDL-C still >130 mg"dL, $% 200 mg"dL, may onsider :ile aid

se6uestrant or e;etimi:e5***

→ +n )ig) LDL-C atients, if non-DL-C >1

NOTE:

* =se of drug t)eray limited to )ildren >10 years of age 8it) defined ris rofiles5

** +n a )ild 8it) LDL-C >1'0 mg"dL and ot)er Fs, trial of C+LD 2-LDL-C diet

may :e a::reviated5

*** +n onsultation 8it) a liid seialist5

%uidelines ontain omlete drug ta:les 8it) C$ results, dosages, side effets,

and s)edules5

Abbreviation5 &>x family history

0 p gcont8

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. /aturated fat D? of calories Grade A

Highly

recommend

. "ietar0 cholesterol D:>> #g+d Grade A Highly

recommend

'ith high 2Gs Eli#inate sugar1 GradeB

sweetened %everages7 reduce si#ple ecommend

car%oh0drates7 increase dietar0

o#ega = content weight

#anage#ent as needed8

CHIL" :1L"L and CHIL" :1

2G

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• *O++ adolescents ,* to ,O years of age $hohad


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IN2EG*2E" C*"I$,*/C3L* HE*L2H/CHE"3LE

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Integrated Cardiovascular Health


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Birth@;:#

;@0 @0 @;;0 ;:@;0 ;J@:;0

Hx ofE*L9C,"

*2 =97E,*L3*2EHx $E*L9 C,"5Parentsgrandparentsaunts3unclesM XWWy &XWy. evie$

$ith parents.efer prn.

)pdate ateach non(urgenthealthencounter.

eevaluate&>x for early9:' ingrandparents parentsauntsuncles MXWWy &XWy. evie$

$ith parents.

)pdate at eachnon(urgenthealthencounter.

epeat &>xevaluation$ith patient.

2$B*CC$EKP$/3E

*",I/E/-$4EEEH$-E8 4Zersmo0ing

cessationassistanceto parents.

9ontinue activeanti(smo0ingcounseling $ithparents.4Zer smo0ingcessation

assistance asneeded.

-eginactive anti(smo0ingcounseling$ith child.

Assesssmo0ingstatus ofchild.4Zer activeanti(smo0ing

counseling orreferral asneeded.

9ontinue activeanti(smo0ingcounseling $ithpatient.4Zer smo0ingcessation

assistance asneeded.

einforcestrong anti(smo0ingmessage.4Zersmo0ing

cessationassistance orreferral asneeded.

N32I2I$

N+ "IE2

Supportbreastfeeding as optimalto ,*m if

possible.Add formula

At ,*6*Lmmay change toco$!s mil0 $ithR fat 1per

family andpediatric care

einforce9>#


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G$'2H

evie$ &>xfor obesity discuss

$eight 1$t2for height1ht2trac0inggro$th

chart andhealthy diet.

CH*2H2+'2+B-I CL*//I9

'EIGH2 B9B-I7 $-*GE : and revie$ $ithparent.

9hart>T3?T3-M#and revie$$ith parent.-M# KFWthpercentilecrossingpercentiles

intensify diet3activity focusfor months.#f no change registered

dietician 1'2referral.Manage perobesity

algorithms.-M# KEWthpercentilemanage perobesityalgorithms.

9hart>T3?T3-M#

evie$ $ithparent andchild. -M#KFWthpercentilecrossing

percentilesintensify diet3activity focusfor months.#f no change '

referral.Manage perobesity

algorithms.-M# KEWthpercentilemanage perobesityalgorithms.

9hart>T3?T3-M#

evie$ $ithchild andparent.-M# KFWthpercentilecrossing

percentilesintensify diet3activity focusfor months.#f no change ' referral

Manage perobesityalgorithms.

-M# KEWthpercentilemanage perobesityalgorithms.

evie$>T3?T3-M#and norms forhealth $ithpatient.-M# KFWthpercentilecrossing

percentilesintensify diet3activity focusfor months.#f no change ' referral.

Manage perobesityalgorithms.

-M# KEWthpercentilemanage perobesityalgorithms.

Birth@

;:#

;@0 @0 @;;0 ;:@;0 ;J@:;0

Integrated Cardiovascular Health/chedule cont8

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• _;xpert Panel on #ntegrated =uidelines for9ardiovascular >ealth and is0 eduction in

9hildren and Adolescents5 Summary eport`

published as a Supplement in the 'ecemberissue of Pediatrics 1*+,,H,*F5S*,NGS*W2available at5 http533pediatrics.aappublications.org3content3,*F3SupplementUW.toc

• &ull eport Summary eport and ;vidence Tables available on the C>


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• The guidelines $ere extensively revie$ed by >>Sprofessional groups and the public before release.

• ;ndorsed by the American Academy of Pediatrics.

• Support materials developed by C>


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or #ore infor#ation

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