DEPARTMENT: Progress in Prevention
Atherosclerotic cardiovascular disease (CVD) remains a major cause of morbidity and premature mortality in men and women in the United States and most developed and developing countries.1 Although manifest CVD is rare in childhood and adolescence, risk factors and adverse health behaviors that accelerate the development and progression of atherosclerosis begin in childhood. Evidence accumulated over the past several decades underscores the importance of cardiovascular health promotion and risk reduction beginning early in life and prompted a series of guidelines focused on children and youth.2–4 More recently, the former director of the National Heart, Lung, and Blood Institute (NHLBI), Dr Elizabeth Nabel, initiated the development of cardiovascular health guidelines for pediatric providers with emphasis on an integrated format designed to address all the major cardiovascular risk factors simultaneously.5,6 Available on the NHLBI Web site5 and published in a recent supplement to Pediatrics,6 these evidence-based guidelines were designed to assist all primary pediatric care providers in both the promotion of cardiovascular health and the identification and management of specific risk factors from infancy into young adult life.
The recommendations included in the guidelines address 2 different goals: the prevention of risk factor development (primordial prevention) and the prevention of CVD by effective identification and management of risk factors (primary prevention). Important to highlight in this context is the innovative approach used in the evidence review. Normally, systematic evidence reviews include 1 question that addresses the impact of specific interventions on specific health outcomes. In such reviews, evidence is usually limited to randomized controlled trials (RCTs) and meta-analyses that meet specific criteria for inclusion and were published within a defined time period. Because the guidelines for children and adolescents address atherosclerosis, a disease process rather than a clinical endpoint, the evidence review addressed a range of questions focused on development, progression, and management of multiple risk factors extending from birth through 21 years of age, including the few available studies with follow-up data points in later adult life. In the absence of long-term, longitudinal studies (ie, RCTs) illustrating that risk reduction in childhood prevents incident CVD in adult life, the review included epidemiologic observational studies, a critical appraisal of the body of evidence that addresses the impact of preventing and managing risk factors in childhood on both the development and progression of atherosclerosis, and evidence that justifies evaluation and treatment of risk factors in childhood. Adapted from the American Academy of Pediatrics,7 the schema used in grading the evidence was as follows: (a) well-designed RCTs or diagnostic studies performed on a population similar to the guideline’s target population; (b) RCTs or diagnostic studies with minor limitations; genetic natural history studies; (c) observational studies (case-control and cohort design); and (d) expert opinion, case reports, or reasoning from first principles (bench research or seminal studies).
The NHLBI expert panel integrated guidelines for cardiovascular health and risk reduction in children and adolescents include recommendations that are based on the evidence review and directed toward all primary pediatric care providers including pediatricians, family practitioners, nurses and nurse practitioners, physician assistants, and registered dietitians. The age-based recommendations (by risk factor) are included in the Table; additional information on the state-of-the-science, methodology of the evidence review, processes used in guideline development, and summaries of the evidence review by risk factor are available on the NHLBI Web site.5
Cardiovascular nurses are encouraged to become fully informed of these new evidence-based, integrated guidelines and advocate for implementation across healthcare settings. Cardiovascular nurses in primary care settings are well positioned to implement these evidence-based guidelines designed to promote cardiovascular health and CVD risk reduction for all children and adolescents.
1. Lloyd-Jones D, Adams R, Brown TM, et al.. Heart disease and stroke statistics–2010 update: a report from the American Heart Association. Circulation. 2010; 121: e46–e215.
2. NCEP Expert Panel on Blood Cholesterol Levels in Children and Adolescents. National Cholesterol Education Program (NCEP): highlights of the report of the Expert Panel on Blood Cholesterol Levels in Children and Adolescents. Pediatrics. 1992; 89 (3): 495–501.
3. Kavey RE, Daniels SR, Lauer RM, Atkins DL, Hayman LL, Taubert KR. American Heart Association guidelines for primary prevention of atherosclerotic cardiovascular disease beginning in childhood. Circulation. 2003; 107: 1562–1566.
4. Kavey RE, Allada V, Daniels SR. Cardiovascular risk reduction in high-risk pediatric patients: a scientific statement from the American Heart Association. Circulation. 2006; 114 (24): 2710–2738.
5. Daniels SR, Benuck I, Christakis DA, et al. NHLBI full and summary report of the Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents. http://www.nhlbi.nih.gov/
. Accessed January 15, 2012.
6. Kavey RE, Simons-Morton DG, de Jesus JM, suppl eds . Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: summary report. Pediatrics. 2011; 125 (suppl 5): S213–S256.
7. American Academy of Pediatrics. Steering Committee on Quality Improvement and Management. Classifying recommendations for clinical practice guidelines. Pediatrics. 2004; 114 (3): 874–877.