Carotid Intima–Media Thickness in Children and Adolescents With Congenital Heart Disease

Trends in Nutritional Status and Dietary Behavior in School-Aged Children with Congenital Heart Defects

Background: Malnutrition and poor weight gain has been reported in infants with congenital heart defects (CHDs); however data in older children with CHDs are limited. In order to obtain representative data on the nutritional status, dietary behavior, and potential influencing factors in school-aged children with CHDs, we performed a nationwide online survey. Methods: Patients aged 6 to 17 years registered in the German National Register for CHDs were asked to participate in this study by completing the German Health Interview and Examination Survey for Children and Adolescents (KiGGS) eating study questionnaire in order to assess their self-reported dietary habits. The use of the same questionnaire enabled a comparison with a representative subset of 4569 participants of the KiGGS study. Results: A total of 894 patients (mean age 12.5 ± 3.0 years; 47.2% female) were enrolled. Patients were allocated according to anatomic complexity into simple (23.8%), moderate (37.8%), and complex CHDs (38.4%). The consumption of sugar-containing food (p < 0.001) and fast food (p < 0.05) was significantly lower among the CHD patients than in the healthy children. Children with CHDs showed significantly lower body mass index (BMI) percentiles (p < 0.001) compared with their healthy peers, while children with complex and moderate CHDs had the lowest BMI. While in CHD patients, the BMI percentiles were not related to unhealthy food, there was a strong correlation with the CHD severity and number of previous interventions (p < 0.01). Conclusions: According to this nationwide survey, school-aged children with complex CHD are at risk of undernutrition, which is not due to dietary habits but to CHD severity and repeated surgery.

[Cardiovascular diseases in the young patients : Place of the carotid intima-media thickness at the University Hospital-Ibn Rochd of Casablanca]

BACKGROUND

The measurement of intima-media thickness (IMT), long neglected, is a fundamental element in the prediction of cardiovascular events. Vascular Doppler ultrasonography is one of the tools needed to objectify atherosclerosis.

OBJECTIVES

The aim of our study is to establish a correlation between cardiovascular events and intima-media thickness.

METHODS

We conducted a prospective, cross-sectional and descriptive study over a period of 6 months in the cardiology department of Chu-Ibn Rochd, based on vascular Doppler ultrasound data, presenting a risk factor and or vascular cardiovascular disease of the supra-aortic trunks using a high frequency linear probe (7.5 MHZ) connected to a GENERAL Electric ultrasound machine. Intima-media thickness was considered normal < 0.8 mm in adult patients aged 40-60 years.

RESULTS

IMT ≥ 0.8 mm was found in 89.2% of patients out of a total of 102 patients recruited, predominantly male (54.9%) with a mean age of 56 ± 9 years. Cardiovascular risk factors and cardiovascular diseases were associated with an increase in IMT. Diabetics were the most frequent to have an elevated IMT, found at 50.9%, followed by 43.1% of hypertensives, 27.4% respectively between haemodialysis patients and ischemic strokes and 14% in coronary patients with indication of bypass surgery.

CONCLUSIONS

Elevated IMT is associated with cardiovascular events and should be sought as their primary indicator in future large-scale studies so that it can be routinely assessed for a cardiovascular risk factor.

Ultra-processed food intake is associated with children and adolescents with congenital heart disease clustered by high cardiovascular risk factors

The excessive intake of ultra-processed foods (UPF) is associated with an increase in cardiovascular risk. However, the effect of UPF intake on cardiovascular health in children and adolescents with congenital heart disease (CHD) is unknown. The aim of the present study was to describe UPF intake and evaluate associations with isolated cardiovascular risk factors and children and adolescents with CHD clustered by cardiovascular risk factors. A cross-sectional study was conducted involving 232 children and adolescents with CHD. Dietary intake was assessed using three 24-hour recalls. UPF were categorised using the NOVA classification. The cardiovascular risk factors evaluated were central adiposity, elevated high-sensitivity C-reactive protein (hs-CRP) and subclinical atherosclerosis. The clustering of cardiovascular risk factors (waist circumference, hs-CRP and carotid intima-media thickness) was performed, allocating the participants to two groups (high v. low cardiovascular risk). UPF contributed 40·69 % (sd 6·21) to total energy intake. The main UPF groups were ready-to-eat and take-away/fast foods (22·2 % energy from UPF). The multivariable logistic regression revealed that an absolute increase of 10 % in UPF intake (OR = 1·90; 95 % CI: 1·01;3·58) was associated with central adiposity. An absolute increase of 10 % in UPF intake (OR = 3·77; 95 % CI: 1·80, 7·87) was also associated with children and adolescents with CHD clustered by high cardiovascular risk after adjusting for confounding factors. Our findings demonstrate that UPF intake should be considered as a modifiable risk factor for obesity and its cardiovascular consequences in children and adolescents with CHD.

Clusters of lifestyle behaviors associated with atherosclerosis risk factors in children and adolescents with congenital heart disease: Floripa CHild Study

Secondary cardiovascular disease is the main cause of mortality in congenital heart disease (CHD) patients. The cardiovascular risk could be widely prevented with adherence to a healthy lifestyle; however, clusters of lifestyle behaviors related to atherosclerosis risk factors in children and adolescents with CHD remain unclear. We aimed to describe the clusters of lifestyle behaviors of children and adolescents with CHD and to evaluate their association with atherosclerosis risk factors. We conducted a cross-sectional study on 227 children and adolescents with CHD (median age:10.02 [IQR:7.08-13.02] years). Dietary intake, physical activity (PA), and sedentary behavior (SB) were evaluated. Clusters of lifestyle behaviors were determined using a two-step cluster analysis. Atherosclerosis risk factors evaluated include body fat mass, central obesity, blood pressure, lipid parameters, glucose, C-reactive protein, and carotid intima-media thickness (cIMT). Multiple logistic regressions were used. The "unhealthy: high SB + low PA" cluster was associated with elevated body fat mass, central obesity, and elevated cIMT. Furthermore, the "unhealthy: low PA + unhealthy eating habits" cluster was associated with elevated body fat mass, central obesity, and elevated glucose. The unhealthier lifestyle behavior clusters were associated with atherosclerosis risk factors in children and adolescents with CHD. Multidisciplinary strategies to promote healthy behaviors are needed to prevent cardiovascular disease in later life.

Increased carotid intima-media thickness and reduced health-related physical fitness in children and adolescents with coarctation of the aorta

Background

Coarctation of the Aorta (CoA) was assumed to be one of the congenital heart defects not associated with major long-term sequels. Meanwhile, it is known that there are long-term cardiovascular consequences. This study investigates the functional outcome measures in children with CoA.

Methods

77 children (40.3% girls, 13.1 ± 3.3 years) with CoA were examined for their functional outcome measures and compared to healthy controls (CG). Carotid Intima-Media wall thickness (cIMT) was measured by ultrasound of the common carotid artery. In addition, Health-related Physical Fitness (HrPF) was assessed by five tasks of the FITNESSGRAM® and health-related quality of life (HrQoL) was analyzed with a self-report questionnaire (KINDL-R).

Results

After adjustment for age and sex and in comparison to the CG, the CoA patients showed structural changes in cIMT (CoA: 0.480 ± 0.043 mm vs CG: 0.465 ± 0.033 mm; p = 0.002) and significantly lower HrPF (z-score -0.46 ± 0.7; p < 0.001; 32nd percentile). HrQoL in children with CoA was significantly better in comparison to CG (p = 0.020).

Conclusion

Early onset of structural changes of the cIMT in children with CoA could be shown. These structural changes in combination with hypertension, which often is associated with CoA, should be the focus of structured follow-up during childhood. The children with CoA showed impaired HrPF in comparison, where the promotion of physical activity should be the key factor for improvement. Encouragingly they showed better HrQoL.

Common carotid artery characteristics in patients with repaired aortic coarctation compared to other cardiovascular risk factors

Aims

Increased common carotid artery (CCA) intima media thickness (cIMT) is a well-known risk factor for cardiovascular morbidity and mortality. cIMT thickening has been described in patients with repaired aortic coarctation (CoA), but data on mechanism and clinical relevance in this population are scarce. Our aim was to gain mechanistic insights into cIMT thickening of patients with repaired CoA by comparing their wall architecture to patients with coronary artery disease (CAD), other congenital heart diseases (oCHD), and healthy controls.

Methods and results

A total of 310 subjects were included (CoA (n ​= ​58), oCHD (n ​= ​96), CAD (n ​= ​68) and healthy controls (n ​= ​88)). CIMT and lumen diameter (LD) were determined using semiautomated analysis software. Linear regression analyses were performed correcting for relevant covariates. While patients with repaired CoA and CAD both had significantly increased cIMT and cIMT/LD ratios, LD was increased only in CoA patients. Furthermore, patients with repaired CoA had decreased CCA stiffness. CCA characteristics in the oCHD group were not significantly different from controls.

Conclusion

The mechanism of cIMT thickening in patients with repaired CoA may differ from CAD. While there is concentric remodeling in the latter, we see predominant eccentric remodeling in the CoA group, which could be due to increased flow as a result of compliance mismatch at the CoA repair site. We therefore suggest that the prognostic value of cIMT in post-CoA patients should be validated separately prior to using it to guide clinical management in this group.

Cardiovascular Function and Exercise Capacity in Childhood Cancer Survivors

Introduction: Childhood cancer survivors (CCS) might be at high risk of additional chronic diseases due to cardiotoxic side effects. The aim of this study was to analyze long-term side effects of cancer therapy on vascular structure/function, cardiac biomarkers and on physical activity. Methods: In total, 68 asymptomatic patients aged 16–30 years with childhood cancer (diagnosed 10.6 ± 3.9 years ago) were examined from 2015–2020. (Central) blood pressure and pulse wave velocity were registered via the oscillometric method, while carotid intima-media thickness (cIMT) was measured non-invasively by ultrasound. cIMT values of patients were compared to healthy controls (n = 68; aged 22.3 ± 3.5 years). Patients’ exercise capacity was recorded. The plasma N-terminal pro-brain natriuretic protein (NTproBNP) and troponin levels were measured as cardiac biomarkers. CCS were categorized in groups with low, moderate and high anthracyclines. Results: No differences were found in cIMT between patients and controls as well as between patients with various anthracycline dosage. Patients with high dose anthracyclines showed a significant lower performance versus patients with moderate dose anthracyclines (84.4% of predicted VO₂peak; p = 0.017). A total of 11.6% of CCS had abnormal NTproBNP values which correlated with received anthracycline dosage (p = 0.024; r = 0.343). Conclusion: NTproBNP levels and exercise capacity might be early markers for cardiovascular dysfunction in CCS and should be included in a follow-up protocol, while cIMT and troponin seem not to be adequate parameters.

Diminished Endothelial Function but Normal Vascular Structure in Adults with Tetralogy of Fallot

The life expectancy of patients with Tetralogy of Fallot (ToF) has increased in recent years. As a result, other risk factors with later onset in life are in the focus of patient care. Endothelial function is an early indicator of cardiovascular risk and was investigated along further structural vessel properties. A total of 17 patients (41.7 ± 7.1 years, 8 women) with Tetralogy of Fallot were 1:2 matched for sex with 34 (38.9 ± 8.1 years, 16 women) healthy volunteers. Participants received an assessment of their endothelial function and a structural assessment of the aorta. Patients with ToF showed a reduced endothelial function determined by reactive hyperaemia index after adjusting for age, weight and height (ToF: 1.55 ± 0.31 vs. controls: 1.84 ± 0.47; p = 0.023). No differences in carotid intima-media thickness (cIMT) between the ToF and healthy controls (ToF: 0.542 ± 0.063 mm vs. controls: 0.521 ± 0.164 mm; p = 0.319) were found. Patients with ToF had reduced vascular function compared to healthy subjects. As the structural component is not affected, endothelial dysfunction seems not to have yet manifested itself as a morphological change. Nevertheless, long-term management of these patients should include vascular parameters.

Dietary patterns are associated with central adiposity and carotid intima-media thickness in children and adolescents with congenital heart disease

PURPOSE

Unhealthy dietary patterns (DP) in childhood are associated with cardiovascular disease in adulthood. DP in children and adolescents with congenital heart disease (CHD) are unknown. The aims of this study were to describe DPs of children and adolescents with CHD and to evaluate their associations with central adiposity, high-sensitivity C-reactive protein (hs-CRP) and carotid intima-media thickness (cIMT).

METHODS

A cross-sectional study including 232 children and adolescents with CHD. Dietary data were based on three 24-h dietary recalls. Central adiposity was evaluated by waist circumference. hs-CRPs were determined by nephelometry. The cIMT was measured using ultrasound. DPs were identified using principal component analysis. Data were examined using logistic and linear regressions.

RESULTS

Six DPs were identified. In multivariable-adjusted analysis, unhealthy DP (high intake of poultry, red meat, cold cuts and processed meats, soft drinks and sweetened beverages) and healthy DP (high intake of fish, eggs, bread, beans, tubers and roots, fruit and fruit juice) were associated with increased and decreased odds of central adiposity, respectively (Odds ratio (OR): 2.10; 95% confidence interval (95% CI) 1.09; 4.02; OR: 0.48 95% CI 0.24; 0.93). Besides, low-fat dairy DP (high intake of low-fat milk and dairy, mixed dishes, ultra-processed breads, candy and chocolate) was inversely associated with cIMT (β: - 0.024; 95% CI - 0.04; - 0.01).

CONCLUSION

Unhealthy DP seems to increase the risk of central adiposity, while the healthy DP seems to decrease the risk of central adiposity. Still, low-fat dairy DP was inversely associated with cIMT. These findings may be helpful to develop nutrition recommendations for early cardiovascular disease prevention in children and adolescents with CHD.

Subclinical atherosclerosis in children and adolescents with congenital heart disease

BACKGROUND

Subclinical atherosclerosis in childhood can be evaluated by carotid intima-media thickness, which is considered a surrogate marker for atherosclerotic disease in adulthood. The aims of this study were to evaluate carotid intima-media thickness and, to investigate associated factors.

METHODS

Cross-sectional study with children and adolescents with congenital heart disease (CHD). Socio-demographic and clinical characteristics were assessed. Subclinical atherosclerosis was evaluated by carotid intima-media thickness. Cardiovascular risk factors, such as physical activity, screen time, passive smoke, systolic and diastolic blood pressure, waist circumference, dietary intake, lipid parameters, glycaemia, and C-reactive protein, were also assessed. Factors associated with carotid intima-media thickness were analysed using multiple logistic regression.

RESULTS

The mean carotid intima-media thickness was 0.518 mm and 46.7% had subclinical atherosclerosis (carotid intima-media thickness ≥ 97th percentile). After adjusting for confounding factors, cyanotic CHD (odds ratio: 0.40; 95% confidence interval: 0.20; 0.78), cardiac surgery (odds ratio: 3.17; 95% confidence interval: 1.35; 7.48), and be hospitalised to treat infections (odds ratio: 1.92; 95% confidence interval: 1.04; 3.54) were associated with subclinical atherosclerosis.

CONCLUSION

Clinical characteristics related to CHD were associated with subclinical atherosclerosis. This finding suggests that the presence of CHD itself is a risk factor for subclinical atherosclerosis. Therefore, the screen and control of modifiable cardiovascular risk factors should be made early and intensively to prevent atherosclerosis.

Identified plasma proteins related to vascular structure are associated with coarctation of the aorta in children

BACKGROUND

Coarctation of the aorta (CoA), presenting with local stenosis of the aorta is involved in many cardiovascular processes. However, there has been little research on the mechanism of coarctation of the aorta.

METHODS

Altered proteins were identified by isobaric tag for relative and absolute quantitation (iTRAQ) technology in 8 participants, and further analysed by heatmap, Gene Ontology (GO), Kyoto Encyclopedia of Genes and Genomes pathway (KEGG) and Search Tool for the Retrieval of Interacting Gene (STRING). Of these, two vascular structure-related proteins were further validated by using enzyme-linked immunosorbent assay (ELISA) in a new cohort of CoA patients.

RESULTS

39 differentially expressed plasma proteins were first identified in patients with coarctation of the aorta by iTRAQ. Of these, fibulin-1 (FBLN1) and insulin-like growth factor-binding protein complex acid labile subunit (ALS) were considered candidates and further validation also showed that the level of FBLN1 in the CoA group (8.92 ± 2.36 μg/ml) was significantly higher compared with control group (6.13 ± 1.94 μg/ml), and the level of ALS in CoA children (348.08 ± 216.74 ng/ml) was significantly lower than the level in normal children (619.46 ± 274.08 ng/ml).

CONCLUSIONS

The differentially expressed proteins identified in the plasma from CoA patients indicated that they may play critical roles in CoA and that they could potentially be utilized as biomarkers for diagnosis. Altered vascular related proteins were associated with COA. These results provide a foundation for further understanding and studying the aetiology and pathogenesis of coarctation of the aorta.

Vascular Structure and Function in Children and Adolescents: What Impact Do Physical Activity, Health-Related Physical Fitness, and Exercise Have?

A physically active lifestyle can prevent cardiovascular disease. Exercise intervention studies in children and adolescents that aim to increase physical activity have resulted in reduced vascular wall thickening and improve cardiovascular function. Here we review the literature that explores the correlations between physical activity, health-related physical fitness, and exercise interventions with various measures of vascular structure and function in children and adolescents. While several of these studies identified improvements in vascular structure in response to physical activity, these associations were limited to studies that relied on questionnaires. Of concern, these findings were not replicated in studies featuring quantitative assessment of physical activity with accelerometers. Half of the studies reviewed reported improved vascular function with increased physical activity, with the type of vascular measurement and the way physical activity was assessed having an influence on the reported relationships. Similary, most of the studies identified in the literature report a beneficial association of health-related physical fitness with vascular structure and function. Overall, it was difficult to compare the results of these studies to one another as different methodologies were used to measure both, health-related physical fitness and vascular function. Likewise, exercise interventions may reduce both arterial wall thickness and increased vascular stiffness in pediatric populations at risk, but the impact clearly depends on the duration of the intervention and varies depending on the target groups. We identified only one study that examined vascular structure and function in young athletes, a group of particular interest with respect to understanding of cardiovascular adaptation to exercise. In conclusion, future studies will be needed that address the use of wall:diameter or wall:lumen-ratio as part of the evaluation of arterial wall thickness. Furthermore, it will be critical to introduce specific and quantitative measurements of physical activity, as intensity and duration of participation likely influence the effectiveness of exercise interventions.

Is Carotid Intima-Media Thickness Increased in Adults With Congenital Heart Disease?

Background

Because of the increasing numbers of congenital patients surviving into adulthood, early diagnosis and prevention of acquired cardiovascular disease is reasonable. The aim of this study was to detect diagnostic subgroups of adults with congenital heart disease (ACHD) that have increased carotid intima‐media thickness (cIMT), a subclinical marker of cardiovascular damage.

Methods and Results

This study enrolled 831 ACHD patients (392 women, aged 38.8±11.7 years) from May 2015 to February 2019 at their regular outpatient visit. Far wall cIMT was measured using a semiautomatic ultrasound system at 4 angles. Age, sex, height, weight, blood pressure, smoking status, and antihypertensive medication were registered and entered in a multiple linear regression model to compare diagnostic subgroups to 191 healthy controls (111 women, aged 36.7±13.5 years). There were no significant differences in cIMT of ACHD (0.538±0.086 mm) compared with healthy controls (0.541±0.083 mm; P=0.649) after adjusting for the aforementioned covariates. Only patients with coarctation of the aorta showed significantly higher cIMT values (0.592±0.075 mm; P<0.001) compared with healthy controls. In addition, ACHD patients who were men (P=0.032), older (P<0.001), and were prescribed antihypertensive medications (P=0.003) were all found to have thicker cIMT values.

Conclusions

Overall, we determined that within the ACHD cohort, only those patients with a history of coarctation have higher cIMT values. To better determine the mechanism of abnormal vasculature, further basic research is needed.

Health-Related Physical Fitness and Quality of Life in Children and Adolescents With Isolated Left-to-Right Shunt

Objective: Atrial (ASD) and ventricular septal defects (VSD) represent the most common congenital heart defects (CHD) and are considered simple and curable. This study investigates long-term functional outcomes in children with such defects. Patients and Methods : We examined 147 patients (74 girls, 12.1 ± 3.5 years) with isolated shunts (ASD: 54%, VSD: 46%) for their Health-Related Physical Fitness (HRPF) and Health-Related Quality of Life (HRQoL). Native condition was present in 58 patients, interventional closure of the defect was performed in 42 and surgical closure in 47. For comparison, a healthy control group (CG) of 1,724 children (48.9% girls, 12.8 ± 2.8 years) was recruited within two recent school projects. Results: After adjustment for age and sex, children with ASD and VSD presented lower HRPF (z-score healthy peers: 0.02 ± 0.73, ASD: -0.41 ± 0.73, p < 0.001; VSD: -0.61 ± 0.73, p < 0.001) then healthy peers. Transferred into percentiles, VSD were on the 26th and ASD on the 34th percentile of the healthy peers. HRQoL did not differ between peers and CHD with isolated shunts (healthy peers: 76.1 ± 9.7, ASD: 76.2 ± 9.9, p = 0.999; VSD: 78.7 ± 9.7, p = 0.316). Regarding the surgical history of the shunts (native, percutaneously treated, surgically treated), there were also no difference in-between these three states, nor differed HRPF and HRQoL in-between gender. Conclusions: Children with ASD or VSD have impaired HRPF but normal HRQoL. Early childhood sports promotion could be a good measure to counteract these restrictions in HRPF at an early stage.