Cut Points for Lipids and Lipoproteins in Children and Adolescents: Should They Be Reassessed?

Antecedent plasma concentrations of lipids and lipoproteins are associated with both early pathologic lesions of atherosclerosis and arterial changes in vivo, such as carotid intima media thickness (IMT)1 and endothelial dysfunction (1)(2). Healthy normolipidemic Finnish children, treated with a low–saturated fat, low-cholesterol diet from the age of 7 months to 11 years, had less carotid IMT than controls. In Dutch children and adolescents with heterozygous familial hypercholesterolemia (FH), treatment for 2 years with a similar diet and an inhibitor of hydroxymethylglutaryl CoA reductase led to decreased carotid IMT compared to IMT in FH children treated with diet and placebo. Impaired endothelial dysfunction in FH children, as judged by flow-mediated dilation, improved significantly in those treated with simvastatin vs those on placebo, to a level similar to that in healthy non-FH controls.These findings have raised considerable interest in identifying children and adolescents with dyslipidemia and to initiate treatment with diet and, when necessary, with drugs. Screening of children for dyslipidemia has traditionally been focused on those with a positive family history of premature cardiovascular disease (CVD) and those whose parents have CVD or dyslipidemia (primarily hypercholesterolemia). Unfortunately, screening by family history of CVD or hypercholesterolemia fails to detect 17% to 90% of those with significant dyslipidemia (1). Although 50% of offspring of parents with premature CVD will have dyslipidemia, such parents are usually in their 40s, delaying the detection of dyslipidemia in their children. Conversely, considerable data indicate that lipid and lipoprotein concentrations track from childhood into adulthood, especially total cholesterol (TC), LDL-C, non–HDL-C (the estimated cholesterol concentration of all the apolipoprotein B–containing lipoproteins, i.e., TC minus HDL-C) (1). Given all of the above results, the alternative approach of universal screening is receiving greater attention.Screening requires the use of cut points to identify individuals with dyslipidemia. …