The influence of age and relative weight on the presentation of familial combined hyperlipidemia in childhood

Apolipoprotein Particle and Cardiovascular Risk Prediction (from a Prospective Cohort Study)

The present study aimed to examine the association between discordant apolipoprotein B (Apo B) with low-density lipoprotein cholesterol (LDL-C) or non-high-density lipoprotein cholesterol (non-HDL-C) and cardiovascular disease (CVD) risk in the Chinese population and to determine whether adding information on Apo B to LDL-C and HDL-C improves CVD risk prediction. This study collected data from the China Health and Nutrition Survey from 2009 to 2015. Discordant Apo B with LDL-C and non-HDL-C were defined based on residual differences and medians. Logistic regression was used to examine the association between discordant Apo B with LDL-C or non-HDL-C and CVD risk. Areas under the receiver operating characteristic curve and categorical net reclassification improvement were utilized to assess the incremental predictive value of Apo B levels for CVD risk. A total of 7,117 participants were included, the mean age was 50.8 ± 14.3 years, 53.6% were female. During the 6-year follow-up, 207 CVD cases were identified. Participants with discordant high Apo B relative to LDL-C or non-HDL-C were at higher risk of CVD than those with the concordant group (odds ratio 1.38, 95% confidence interval 1.01 to 1.87; odds ratio 1.40, 95% confidence interval 1.01 to 1.94, respectively). However, Apo B had no significant contribution to the predictive value of the China atherosclerotic CVD (ASCVD) risk score (areas under the receiver operating characteristic curve 0.788 for China ASCVD score alone vs 0.790 for China ASCVD score plus Apo B). In conclusion, Apo B has the strongest association with CVD risk in healthy Chinese participants than LDL-C and non-HDL-C. However, it has minimal value in CVD risk assessment and discrimination.

Preventing Premature Atherosclerotic Disease

PURPOSE OF REVIEW

Cardiovascular disease (CVD) can begin in youth. Prevention is essential to reducing the burden of CVD-related risk factors in childhood and disease development in adulthood. This review addresses the clinical scope of CVD prevention, including a review of conditions encountered, proposed diagnostic criteria, and management strategies. We also highlight the impact of the intrauterine environment on the development of CVD risk. Finally, we highlight the potential role of telehealth in the management of pediatric patients with risk factors for premature CVD.

RECENT FINDINGS

Growing evidence suggests that maternal obesity, diabetes, and preeclampsia may play an important role in the development of CVD risk among offspring contributing to the development of known traditional CVD risk factors among offspring. As the prevalence of CVD continues to rise, knowledge as well as appropriate diagnosis and management of primordial and traditional risk factors for CVD is needed. The diagnosis and management of CVD risk factors is a central role of the preventive pediatric cardiologist, but it is imperative that the general physician and other pediatric subspecialists be aware of these risk factors, diagnoses, and management strategies. Finally, telehealth may offer an additional method for providing preventive care, including screening and counseling of at risk children and adolescents for traditional risk factors and for providing education regarding risk factors in cases of long distance care and/or during periods of social distancing.

Evaluation of efficacy and safety of Reteplase and Alteplase in the treatment of hyper-acute cerebral infarction

Objective: The present study aimed to investigate the efficacy and safety of Reteplase (rPA) and Alteplase (rt-PA) in the treatment of hyper-acute cerebral infarction (CI).

Methods: Six hundred and eleven patients with hyper-acute CI selected from September 2014 to September 2016 were assigned into the aspirin, rt-PA, rPA, rt-PA + aspirin, and rPA + aspirin groups based on their willingness. The difference of efficacy in five groups were evaluated with National Institute of Health Stroke Scale (NIHSS), modified rankin scale (mRS), and Barthel Index (BI). Coagulation function, blood lipid, and hemodynamics were analyzed. The safety differences were compared by observing the adverse reactions.

Results: Compared with the rt-PA, rPA, and aspirin groups, NIHSS score, mRS score, the incidence of non- and symptomatic cerebral hemorrhage as well as the rate of adverse reactions were decreased, while BI were increased in the rt-PA + aspirin and rPA + aspirin groups after treatment. Compared with the rt-PA and rPA groups, total cholesterol (TC), triacylglycerol (TG), low-density lipoprotein cholesterol (LDL-C), and high-density lipoprotein cholesterol (HDL-C) levels were lower, whereas the hematocrit, whole blood high shear viscosity, whole blood low shear viscosity, plasma viscosity, erythrocyte electrophoresis time, fibrinogen, erythrocyte sedimentation rate (ESR), K value in blood sedimentation equation, and the comprehensive abnormality degree of blood rheology were higher in the rt-PA + aspirin and rPA + aspirin groups.

Conclusion: The efficacy and safety of rt-PA or rPA combined with aspirin in the treatment of hyper-acute CI were better than those of rPA or rt-PA monotherapy.

Discordance Between Apolipoprotein B and LDL-Cholesterol in Young Adults Predicts Coronary Artery Calcification: The CARDIA Study

BACKGROUND

High levels of apolipoprotein B (apoB) have been shown to predict atherosclerotic cardiovascular disease (CVD) in adults even in the context of low levels of low-density lipoprotein cholesterol (LDL-C) or non-high-density lipoprotein cholesterol (non-HDL-C).

OBJECTIVES

This study aimed to quantify the associations between apoB and the discordance between apoB and LDL-C or non-HDL-C in young adults and measured coronary artery calcium (CAC) in midlife.

METHODS

Data were derived from a multicenter cohort study of young adults recruited at ages 18 to 30 years. All participants with complete baseline CVD risk factor data, including apoB and year 25 (Y25) CAC score, were entered into this study. Presence of CAC was defined as having a positive, nonzero Agatston score as determined by computed tomography. Baseline apoB values were divided into tertiles of 4 mutually exclusive concordant/discordant groups, based on median apoB and LDL-C or non-HDL-C.

RESULTS

Analysis included 2,794 participants (mean age: 25 ± 3.6 years; body mass index: 24.5 ± 5 kg/m(2); and 44.4% male). Mean lipid values were as follows: total cholesterol: 177.3 ± 33.1 mg/dl; LDL-C: 109.9 ± 31.1 mg/dl; non-HDL-C: 124.0 ± 33.5 mg/dl; HDL-C: 53 ± 12.8 mg/dl; and apoB: 90.7 ± 24 mg/dl; median triglycerides were 61 mg/dl. Compared with the lowest apoB tertile, higher odds of developing Y25 CAC were seen in the middle (odds ratio [OR]: 1.53) and high (OR: 2.28) tertiles based on traditional risk factor-adjusted models. High apoB and low LDL-C or non-HDL-C discordance was also associated with Y25 CAC in adjusted models (OR: 1.55 and OR: 1.45, respectively).

CONCLUSIONS

These data suggest a dose-response association between apoB in young adults and the presence of midlife CAC independent of baseline traditional CVD risk factors.

Primary hypertriglyceridemia in children and adolescents

Primary disorders of lipid metabolism causing hypertriglyceridemia (HyperTG) result from genetic defects in triglyceride synthesis and metabolism. With the exception of lipoprotein lipase deficiency, these primary HyperTG disorders usually present in adulthood. However, some are unmasked earlier by precipitating factors, such as obesity and insulin resistance, and can be diagnosed in adolescence. Physical findings may be present and can include eruptive, palmer, or tuberoeruptive xanthomas. Triglyceride levels are very high to severe and can occur in the absence or the presence of other lipid abnormalities. Each of the causes of HyperTG is associated with an increased risk to develop recurrent pancreatitis and some may increase the risk of premature cardiovascular disease. Adoption of a healthy lifestyle that includes a low-fat diet, optimizing body weight, smoking avoidance/cessation, and daily physical activity is the first line of therapy. Pharmacologic therapies are available and can be beneficial in select disorders. Here, we review the causes of primary HyperTG in children and adolescents, discuss their clinical presentation and associated complications including the risk of pancreatitis and premature cardiovascular disease, and conclude with management and novel therapies currently in development. The goal of this article is to provide a useful resource for clinicians who may encounter primary HyperTG in the pediatric population.

Lipid management in children

Atherosclerosis begins in childhood, and early initiation of prevention through behavioral means may lower the risk of future cardiovascular disease. The obesity epidemic threatens the cardiovascular health of today's children. Genetic dyslipidemias such as familial hypercholesterolemia and the presence of multiple risk factors in the same child or adolescent may require pharmacologic therapy.

LDL particle size, fat distribution and insulin resistance in obese children

BACKGROUND

The importance of small dense low-density lipoprotein (sdLDL) cholesterol in coronary heart disease has been demonstrated in many studies. Body fat accumulation, especially abdominal adiposity, is one of the important factors modifying the expression of sdLDL in adults.

OBJECTIVE

To determine the prevalence of sdLDL in obese children, and to investigate its relationship with anthropometric and metabolic variables.

SUBJECTS

A total of 30 obese children (22 males, 8 females) aged 12.6+/-0.6 years (mean+/-s.e.), who presented to our outpatient clinic with obesity.

METHODS

LDL peak particle diameter was determined using gel electrophoresis. LDL subclasses were classified into sdLDL (pattern B; diameter<25.5 nm) and non-sdLDL (pattern A; diameter>or=25.5 nm). Anthropometric and metabolic variables were also determined to identify factors modifying LDL particle size.

RESULTS

sdLDL was detected in 11 children (40.0%). In children with sdLDL, waist/height ratio was significantly higher (P=0.0466), and they had significantly higher triglyceride (TG) (P=0.0035) and lower high-density lipoprotein cholesterol (HDLC) levels (P=0.036). Peak LDL diameter as a continuous variable was significantly correlated with HDLC and TG levels. In multiple regression analysis, body mass index and waist/height ratio were significant determinants of the peak LDL diameter variability.

CONCLUSIONS

We found a high prevalence of sdLDL in obese children, and a relationship of peak LDL diameter with abdominal fat accumulation, HDLC and TG levels. The presence of sdLDL might be an important risk factor for the metabolic syndrome.

Rat model of familial combined hyperlipidemia as a result of comparative mapping

Total genome scan was carried out in 266 F2intercrosses from the Prague hypertriglyceridemic (HTG) rat that shares several clinical characteristics with human metabolic syndrome. Two loci for plasma triglycerides (TG) were localized on chromosome 2 (Chr 2) (LOD 4.4, 3.2). The first locus overlapped with the rat syntenic region of the human locus for the metabolic syndrome and for small, dense LDL, while the second overlapped with the syntenic region of another locus for small, dense LDL in humans by the comparative mapping approach. Loci for TG on rat Chr 13 (LOD 3.3) and Chr 1 (LOD 2.7) overlapped with the syntenic region of loci for human familial combined hyperlipidemia (FCHL) in Finnish and Dutch populations, respectively. The concordances of loci for TG localized in this study with previously reported loci for FCHL and its related phenotypes are underlying the generalized importance of these loci in dyslipidemia. These data suggest the close relationship between dyslipidemia in HTG rats and human FCHL, establishing a novel animal model for exploration of pathophysiology and therapy based on genomic determinants.

Familial combined hyperlipidemia (FCHL) in children: the significance of early development of hyperapoB lipoproteinemia, obesity and aging

It is not easy to make diagnose FCHL in children, since a clear expression of lipoprotein abnormality is unlikely and standard criteria have not yet been established. We investigated eight cases of childhood FCHL and their families with respect to familial history, anthropometric parameters and serum lipoprotein levels, to explore the characteristics of childhood FCHL. To diagnose childhood FCHL it is necessary to clarify both the family history and lipid profiles of the parents. In this study, two prominent features were suggested; that serum TG level is affected by both obesity and age, and also in particular, that a significantly elevated level of serum apoB is a predominant feature of FCHL in childhood. It was found that hyperapoB may be revealed antecedently without other lipid abnormalities at an early age. Regardless of other lipoprotein abnormality, it was suggested that hyperapoB might be added to the early diagnostic criteria for FCHL.

Screening for Familial Combined Hyperlipidemia in Children Using Lipid Phenotypes

The purpose of this study was to screen for FCHL in children using serum lipid phenotypes. The subjects were 1190 (599 male, 591 female) children who participated in a screening and care program for life style-related diseases in school children. Total cholesterol, high-density lipoprotein cholesterol and triglyceride were determined, and information on the family history of parents was obtained by questionnaire. Candidates for FCHL were screened by the following criteria; type IIb hyperlipidemia, type IIa hyperlipidemia with positive family history of CHD, hyperlipidemia or both. We informed them of the results by mail. A second series of examinations to diagnose FCHL was performed on volunteer participants, including their parents. The candidates consisted of 9 children with type IIb and 27 with type IIa hyperlipidemia, 11 of whom participated, in the second series of examinations, in which 5 children were diagnosed with FCHL. The prevalence was 0.4%, suggesting that at least half of all individuals with FCHL already demonstrate hyperlipidemia in childhood.

Persistent hypercholesterolemia is associated with the development of obesity among girls: the Bogalusa Heart Study

BACKGROUND

Obesity is associated with cardiovascular disease (CVD) risk factors. Cross-sectional data suggest that hypercholesterolemia is associated with the development of childhood obesity.

OBJECTIVE

The objective was to assess age-related changes in relative weight and the association between relative weight and CVD risk factors in hypercholesterolemic and nonhypercholesterolemic children who were nonobese at baseline.

DESIGN

Data on relative weight and CVD risk factors were extracted from the Bogalusa Heart Study for nonobese 5-6-y-old black and white hypercholesterolemic (LDL cholesterol > 75th percentile; n = 58) and nonhypercholesterolemic (LDL cholesterol < 60th percentile; n = 215) children (41% black, 52% girls) who were also assessed 3 and 6 y later. Changes in body mass index (BMI) and CVD risk factors were assessed as a function of age, sex, race, and cholesterol concentration.

RESULTS

BMI increased more in the hypercholesterolemic (n = 31) than in the nonhypercholesterolemic (n = 111) girls during the 6 y of follow-up but was not significantly different between hypercholesterolemic (n = 27) and nonhypercholesterolemic (n = 104) boys aged 5-12 y. Associations between BMI and the risk factors blood pressure, insulin, and blood lipids were observed to be stronger with increasing age and, in some cases, stronger in hypercholesterolemic children and girls.

CONCLUSIONS

Hypercholesterolemia is associated with increased relative weight in girls. The increased relative weight, even at an early age, is associated with a deleterious effect on blood lipids and other CVD risk factors in hypercholesterolemic children, although the strength of these associations is sex dependent.

Childhood obesity

The pediatrician's approach to overweight was best summarized by Bruch 25 years ago: The pediatrician plays an important role in the prevention of obesity. From birth on, feeding a child always involves a dual task--namely, offering food in appropriate amounts and gearing it to the child's expression of his needs. Only in this way can he develop discriminating awareness and become active in establishing self-regulation.... If a child is fed when he is hungry, played with when he needs attention, and encouraged to be active when he is restless, he is not likely to grow up inhibited and passive or overstuffed and helpless, unable to control his eating because every discomfort is misinterpreted as a need to eat.

Role of lipid-lowering pharmacotherapy in children

For patients with coronary artery disease and healthy middle-aged or older individuals with elevated cholesterol levels, treatment with cholesterol-lowering drugs reduces morbidity and sometimes mortality. Treatment reverses established atherosclerotic lesions within a relatively short period of time, suggesting that starting cholesterol-lowering drugs in adulthood is adequate for most people at risk. Children with genetic lipid disorders, including familial hypercholesterolaemia and familial combined hyperlipidaemia, may be candidates for earlier therapy. A complete assessment of risk factors should be undertaken to determine which children are at highest risk. Treatment should start with diet, because diet is an important independent protective factor for disease. The bile acid sequestrants (resins) are the only drugs approved for children and may reduce low density lipoprotein (LDL)-cholesterol levels by 15 to 20% at best. Long term tolerability is good, but many children will not take the resins because they find them unpalatable. Tablet formulations have higher acceptability. Some children require supplementation with fat soluble vitamins or folate. Although hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase inhibitors have not been tested in long term studies in children, safety records are excellent in adults. Short term studies show that HMG-CoA reductase inhibitors reduce LDL-cholesterol levels similarly in children and in adults. Thus, the drugs may be used in low dosages to treat some adolescents with exceptional risk of disease.

Childhood obesity

Approximately 10% of children are obese. Twin and adoption studies demonstrate a large genetic component to obesity, especially in adults. However, the increasing prevalence of obesity over the last 20 years can only be explained by environmental factors. In most obese individuals, no measurable differences in metabolism can be detected. Few children engage in regular physical activity. Obese children and adults uniformly underreport the amount of food they eat. Obesity is particularly related to increased consumption of high-fat foods. BMI is a quick and easy way to screen for childhood obesity. Treating childhood obesity relies on positive family support and lifestyle changes involving the whole family. Food preferences are influenced early by parental eating habits, and when developed in childhood, they tend to remain fairly constant into adulthood. Children learn to be active or inactive from their parents. In addition, physical activity (or more commonly, physical inactivity) habits that are established in childhood tend to persist into adulthood. Weight loss is usually followed by changes in appetite and metabolism, predisposing individuals to regain their weight. However, when the right family dynamics exist--a motivated child with supportive parents--long-term success is possible.

A study of insulin resistance using the minimal model in nondiabetic familial combined hyperlipidemic patients

The presence of insulin resistance in 20 male nondiabetic patients with familial combined hyperlipidemia (FCH) and 20 controls of similar age and body mass index (BMI) was investigated using the minimal model method modified by the administration of insulin and an oral glucose tolerance test. The peripheral sensitivity of insulin, expressed as the insulin sensitivity index (Si), was 1.91+/-1.05 and 2.86+/-1.19 x 10(-4) x min(-1) x mU/L in FCH patients and controls, respectively (P < .01), and the corresponding value for the peripheral utilization of glucose independently of insulin (Sg) was 1.70+/-1.13 in FCH patients and 2.35+/-0.60 x 10(-2) x min(-1) in controls (P < .02). In the FCH group, the Si value correlated significantly (P < .05) with the waist to hip ratio (WHR), plasma triglycerides (TG), free fatty acids (FFA), and the area under the curve of glucose (AUCg) and insulin (AUCi). In the control group, the correlation also reached statistical significance (P < .05) with age, BMI, WHR, blood pressure, TG, AUCg, and AUCi. Subgrouping the subjects with respect to central obesity defined as a WHR of 0.95 or greater, we observed lower Si values in obese and non-obese FCH subjects relative to controls (P < .02). The mean Si value in obese subjects was significantly lower than in non-obese FCH subgroups (1.40+/-0.79 v 2.68+/-0.95 x 10(-4) x min(-1) x mU/L, respectively, P < .01). In conclusion, a higher degree of insulin resistance relative to control values appears to be an integral part of the metabolic derangements observed in FCH, and central-trunk obesity exacerbates the insulin resistance syndrome.

Age-related changes in cardiovascular disease risk factors of hypercholesterolemic children

OBJECTIVE

To describe the age-related changes in cardiovascular disease risk factors in young, hypercholesterolemic (HC) children.

METHODS

Hypercholesterolemic (n = 227) and nonhypercholesterolemic (NHC) (n = 80) children between the ages of 4 and 10 years were identified. Height, weight, skin-fold and blood pressure measurements, and total cholesterol levels were measured. The HC group also had insulin levels evaluated. The groups were compared by analysis of variance. Simple Spearman correlations evaluated the associations between factors within each group.

RESULTS

The HC and NHC groups had similar mean ages, heights, and weights, both contained 51% girls, and all were white subjects. Percent weight-for-height median, and biceps, triceps, suprailiac and subscapular skin-fold measurements were all larger for the HC group. A significant age interaction demonstrated that the HC group's larger suprailiac and sum of skin-fold measures were expressed in the 8.0- to 9.9-year-old children, but not the 4.0- to 5.9-year-olds. For both groups, systolic blood pressure was associated with the measures of adiposity. For the HC group, insulin levels were also associated with adiposity.

CONCLUSIONS

These results suggest that: (1) children with HC have greater body fat, (2) the expression of the hypercholesterolemia precedes the expression of increased body fat, (3) body fat increases with age, and (4) altered insulin and blood pressure levels are expressed in association with the increased body fat in children with HC. Confirmation with longitudinal data is necessary.