The concern for early cardiovascular morbidity and mortality is becoming increasingly more common in the pediatric arena due to the continually increasing incidence of type I and type 2 diabetes mellitus, as well as the rise in obesity in this population. Currently the only treatment recommendations are derived from adult guidelines, due to a lack of evidence-based data in children. Independent risk factors for cardiovascular disease are similar in children and adults: obesity, presence of diabetes, hyperglycemia, insulin resistance, hypertension, and hyperlipidemia. Postmortem studies in children have shown that atherosclerotic plaques begin in childhood, and coronary artery lesions can be seen as early as 10 years of age. The development of atherosclerotic plaques appears to be due to endothelial dysfunction as a result of inflammatory changes from the above listed cardiovascular risk factors. Currently there are several serum markers of inflammation that are predictive of cardiovascular disease in adults, but the significance of changes in the levels of these markers in children is currently unknown. Additionally, there are several noninvasive techniques to measure endothelial dysfunction, including brachial artery reactivity and ECHO Doppler carotid intima-medial thickness, which may ultimately prove to be predictive for cardiovascular disease in children. The management of hypertension in adult patients has been a critical aspect of prevention of cardiovascular disease, but treatment of hypertension in pediatric patients is difficult due to the lack of trials of safety and efficacy in children, as well as lack of, universally accepted standards for the appropriate age and blood pressure level for starting treatment. However, data from adult studies of cardiovascular risk suggest that there would be benefit to early, aggressive control of elevated blood pressure in children. Future studies will be needed to determine which antihypertensive medications will be safe and effective in children, as well as to determine starting points for treatment of hypertension in this population. The treatment of dyslipidemia in adults has resulted in significant risk reduction for cardiovascular morbidity and mortality, but there is a paucity of information available about the long-term safety of using lipid-lowering medications in growing children. Currently, bile acid sequestrants are the only lipid-lowering medication approved for children of all ages, while other lipid-lowering medications are only approved for use in children age 10 and above, and for use in familial hypercholesterolemia. Short-term studies of the statin medications in small groups of male children have shown excellent compliance with no adverse effects on growth, sexual maturation, or hormone levels, but longer-term, more comprehensive studies are needed in the pediatric population. Both the statins and the thiazolidinediones have been shown to have pleotropic effects on the endithelium, which may confer a cardioprotective environment. Treatment of cardiovascular risk factors in childhood consists of a step-wise approach, including lifestyle modification and pharmacologic therapy. Therapy must be individualized based on number of risk factors, family history, and existing complications. Although farther longitudinal studies of medications are needed in children, there may be benefit to following adult guidelines, especially in high-risk adolescents, and instituting early, aggressive treatment for modifiable risk factors.
