April 21, 2015

Heart Meds for Teens?

Over 400,000 more teens would be on heart medications if pediatric guidelines were followed.

The precursors of adult cardiovascular disease are often present in the body during childhood and adolescence, just silent. Teens rarely have heart attacks, angina, or stroke, but their blood vessels nonetheless may still show evidence of the atherosclerotic changes that lead to these catastrophic cardiovascular events.

Atherosclerosis is typically called hardening of the arteries. It begins when abnormal lipids are deposited in the lining of the blood vessels. Ultimately, this can cause blood clots, ruptures, or the loss of blood flow and oxygen to the heart.

The idea is to identify the process of atherosclerosis before it is firmly established and reverse, or stop, its progression before it is too late.

The biggest risk factors for atherosclerosis include abnormal lipid levels, high blood pressure, smoking and tobacco use, metabolic syndrome and obesity.

And when a sedentary child or teen has poor cardiopulmonary — aerobic — fitness along with these health issues, the risk of heart problems is even higher.

The more risk factors a person has, the more severe and extensive the atherosclerotic changes are likely to be. That is why it is important to monitor and address cholesterol issues in childhood and adolescence, before they become symptoms of heart disease in adulthood.

Needed: An Early Warning System

This is particularly true because so many of the conditions that threaten the heart in childhood continue to be present into adulthood: When children and teens are obese, have elevated blood pressure, or abnormally high cholesterol, they are more likely to continue to have these negative health traits as adults.

Since cardiovascular disease often begins silently in childhood and is a major source of mortality in adulthood, guidelines have been developed to begin screening and prevention early in life.

The idea is to identify the process of atherosclerosis before it is firmly established and reverse, or stop, its progression before it is too late. The only problem is, the guidelines for deciding when treatment is needed are different for teens, young adults and adults.

Approximately 400,000 more children and teens might qualify for treatment if the US National Heart, Lung, and Blood Institute (NHLBI) pediatric guidelines for lipid levels, which consider additional cardiovascular risk factors beyond age and LDL concentration, were used in place of adult guidelines, according to a recent study by researchers at Boston Children's Hospital.

Current Treatment Strategies for Children and Teens

There are published recommendations for cardiovascular health risk screening, age-based nutrition and guidelines for physical activity, interventions for tobacco exposure, identification and treatment of elevated blood pressure, and screening and management of high cholesterol/lipids.

When kids have lipid profiles that put them at risk for heart problems, treatment includes addressing issues of overweight /obesity, improving their diets, and using medications when needed.

As adolescents grow into young adulthood, they begin to switch their health care from pediatric to adult providers and receive treatment based on adult parameters.

Young Adults Often Slip Through the Cracks

This is especially challenging when teens are being treated for a condition that is more typically considered an adult medical problem and very often do not yet show symptoms of heart problems.

It can also create some confusion for those treating the older adolescents, ages 17 to 21, because the treatment recommendations for teens and adults are different.

Different Guidelines for Children and Adolescents and Adults

Three groups have published guidelines designed to establish when teens with early signs of heart problems need medical intervention.

The NHLBI guidelines recommend that all teens/young adults, ages 17 to 21 be screened for elevated blood cholesterol and that they be put on cholesterol-lowering medications (statins such as Lipitor, Pravachol, Crestor, Zocor) if they have and LDL (the “bad” cholesterol) of at least 190 mg/dl and no other risk factors, or LDL levels of 130 or 160 mg/dl with additional risk factors.

Six times more patients would be treated if all physicians followed the NHLBI pediatric treatment guidelines.

In contrast, the American College of Cardiology (ACA) and the American Heart Association (AHA) guidelines recommend that adults under 40 years be treated with medication only if their LDL level is at least 190 mg/dl.

This higher LDL cutoff point for adults can lead to confusion for those treating older teens and young adults, and those in that age group who are transitioning to adult care providers and are already on treatment based on the more expansive (i.e., lower LDL) NHLBI pediatric guidelines.

Different Guidelines, Vastly Different Treatment Numbers

The researchers wondered how many 17- to 21-year-olds in the US meets the pediatric criteria and how many meet the adult criteria and how would this affect treatment decisions.

They looked at lipid studies on more than 6300 patients, ages 17 to 21, between 1999 and 2012, and compared the number of 17- to 21-year-olds who would be eligible for treatment with a cholesterol lowering drug based on the NHLBI guidelines vs. the number who would be considered eligible based on the ACA and AHA guidelines.

They found that using the NHLBI guidelines, 2.5% of the older adolescents would meet criteria for medication therapy. Under the adult recommendations a much smaller group, only 0.4 %, would be treated. Finally, compared with those who met the adult guidelines, those who met the children's guidelines had lower average LDL cholesterol levels, but higher rates of other heart disease risk factors, such as high blood pressure, obesity and smoking.

The numbers, when extrapolated to the entire U.S. population, translated to 483,500 teens qualifying for statin treatment as opposed to the 78,200 currently receiving treatment nationally.

That means that six times more patients would be treated if all physicians followed the NHLBI pediatric treatment guidelines.

A Pill Is Not The Only Answer

Addressing cardiovascular health early in life is an important goal. The conflicting advice on when to start medications in this transitional age group means that more study is needed on the long-term benefits and consequences of starting statin therapy early.

A change in eating and exercise habits is a far better long-term strategy for heart health than a lifetime on cholesterol-lowering drugs.

Patients, families, and health care providers must address each case individually, weighing risks and benefits of treatment options and providing ongoing monitoring.

What is clear, however, is that interventions can really help young people avoid problems down the road. Medication is just one of those interventions and it is not a cure-all. Even more important, especially for young adults, is to achieve and maintain an appropriate weight, eat a healthy diet with particular attention to fat intake, exercise, and avoid tobacco.

Medications can help, but it is important for teens, young adults, and their families to realize that medication is not necessarily the only or the best answer. A change in eating and exercise habits is a far better long-term strategy for heart health than a lifetime on cholesterol-lowering drugs.

College age adolescents and their parents should discuss their cardiovascular health and their risk factors with their doctors and identify ways that they can be proactive about their future adult health. When medications are prescribed, compliance with treatment and regular monitoring for effectiveness and side effects are critical for successful treatment.

The study is published in JAMA Pediatrics.

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