Abstract
Cardiovascular diseases caused by atherosclerosis do not typically manifest before middle age; however, the disease process begins early in life. Preclinical atherosclerosis can be quantified with imaging methods in healthy populations long before clinical manifestations present. Cohort studies have shown that childhood exposure to risk factors, such as dyslipidaemia, elevated blood pressure and tobacco smoking, are associated with adult preclinical atherosclerotic phenotypes. Importantly, these long-term effects are substantially reduced if the individual becomes free from the risk factor by adulthood. As participants in the cohorts continue to age and clinical end points accrue, the strongest evidence linking exposure to risk factors in early life with cardiovascular outcomes has begun to emerge. Although science has deciphered the natural course of atherosclerosis, discovered its causal risk factors and developed effective means to intervene, we are still faced with an ongoing global pandemic of atherosclerotic diseases. In general, atherosclerosis goes undetected for too long, and preventive measures, if initiated at all, are inadequate and/or come too late. In this Review, we give an overview of the available literature suggesting the importance of initiating the prevention of atherosclerosis in early life and provide a summary of the major paediatric programmes for the prevention of atherosclerotic disease. We also highlight the limitations of current knowledge and indicate areas for future research.
Key points
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Cohort studies beginning in childhood have shown that children exposed to cardiovascular risk factors are prone to develop preclinical atherosclerosis and cardiovascular events in adulthood.
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The development of atherosclerosis would probably be prevented by maintaining the concentration of apolipoprotein B-containing lipoproteins in the plasma towards their physiological range from an early age.
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Statins have been used to treat dyslipidaemia in children with familial hypercholesterolaemia, and data are emerging indicating that this strategy prevents the development of atherosclerosis in this high-risk group.
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In other paediatric groups, pharmacological treatment as a strategy has not gained wide acceptance due to potential health issues related to the long-term use of pharmaceuticals targeted at children.
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Non-pharmacological interventions in children have provided evidence of modest benefits of lifestyle counselling on risk markers and remain the cornerstones for promoting cardiovascular health in children at the population level.
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In addition to those with familial hypercholesterolaemia, other paediatric groups have an equally high risk of future cardiovascular events, and a consensus on effective strategies to identify and manage these individuals is needed.
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Raitakari, O., Pahkala, K. & Magnussen, C.G. Prevention of atherosclerosis from childhood. Nat Rev Cardiol 19, 543–554 (2022). https://doi.org/10.1038/s41569-021-00647-9
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DOI: https://doi.org/10.1038/s41569-021-00647-9
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