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

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 modalityNutritional approaches are more advisable ways

of treating the cardiovascular risk factor in child and adolesence.

Atherosclerosis usually takes decades to developDisease process itself and the nutritional habits

that propagate the disease begin earlyThe 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)

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

Family History ObesityHypertensionHeart transplant recipients Kawasaki disease Congenital heart disease like : coarctation

and transposition of the great arteries Diabetes mellitus type 1 and type 2

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.

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

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 triglyceridesBody Mass Index ( BMI ) above the 95th percentile

for age in childhood is a risk factor for future metabolic syndrome

• 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

Lipid component : CholesterolTriglyceridaFFA : saturated

unsaturated monounsaturated

polyunsaturated : cis, trans

Several types of lipoproteins, classified by density :

1. Chylomicrons2. VLDL3. LDL4. HDL

History takingPhysical examinationLaboratory finding

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 nervosaHepatic disease• Hepatitis of any etiology• Congenital biliary atresia• Benign recurrent intrahepatic cholestasis

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.

Pediatric lipid treatment programs that employ a multidisciplinary approach are more likely to be successful1. Dietary treatment is the first line of intervention in all childhood dyslipidemias2. Pharmacologic intervention3. Education for lifestyle changes

• 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

Drug mechanism of action

• 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.

1. Thom T, Haase N, Rosamond W, et al. Heart disease and stroke statistics 2006 update. A report from the American Heart Association Statistics Subcommittee. Circulation 2006;113;85-151.

2. Kannel WB. Range of serum cholesterol values in the population developing coronary artery disease. Am J Cardiol 1995;76:69C–77C.

3. Lipid Research Clinics Program. The Lipid Research Clinics Coronary Primary Prevention Trial results II: the relationship of reduction in incidence of coronary heart disease to cholesterol lowering. JAMA 1984;251:365–74.

4. Commitee on Nutrition. Policy Statement : Prevention of pediatric overweight and obesity. Pediatrics 2003;112:424-30.

5. National Cholesterol Education Program. Report of the expert on blood cholesterol levels in children and adolescents. Department of Health and Human Services (US); 1991 Sept. NIG Publication No.: 91-2732.

6. Committee on Nutrition, American Academy of Pediatrics. Statement on cholesterol. Pediatrics 1992;90:469–73.

7. Committee on Nutrition, American Academy of Pediatrics. Cholesterol in childhood. Pediatrics 1998;101:141–7.

8. Gidding SS. New cholesterol guidelines for children circulation 2006;114:989-91.9. Holman RL, Anderson JL, Cannon RO, III, et al. The natural history of

atherosclerosis. Am J Pathol 1958;34:209–35.10. Stary HC. Evolution and progression of atherosclerotic lesions in coronary

arteries of children and young adults. Arteriosclerosis 1989;9 Suppl I:119–32.

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