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A Collaborative Approach to Preventive Cardiology

October 1, 2020
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Many of us have friends or family members who have had an early heart attack. The event is sudden, unexpected and sobering. Those who recover often make drastic changes to their diet and lifestyle, along with taking medications, and endeavor to delay and undo years of accumulated toll. However, these efforts can only go so far because calcified plaques cannot be reversed. Many of these cases are due to familial hypercholesterolemia (FH), which affects approximately 1.3 million people in the United States. Early diagnosis and treatment of FH could prevent many of these cardiovascular events.

We have all seen charts depicting the power of compound interest. A dollar invested early has much greater yield than a dollar invested later – to staggering effect. Like compound interest, early diagnosis and treatment of cardiovascular (CV) risk factors such as hypercholesterolemia and hypertension result in enormous benefits. Children stand to benefit the most from early intervention. A child with long-term untreated LDL-C of 200 mg/dL might have a myocardial infarction (MI) in their late 30s whereas a child with an LDL-C of 125 mg/dL might not have an MI until far later, after age 60. A recent study published in the New England Journal of Medicine found that children treated long-term with statins had fewer cardiovascular events at age 39 years than their affected parents at the same age.

Identifying children with FH has been challenging. The American Academy of Pediatrics recommended universal lipid screening for patients aged 9-11 and 17-21 years starting in 2011. Despite these recommendations, a study in 2017 by Dr. de Ferranti and team found that only around 30% of pediatricians regularly obtained a lipid screen in healthy 9- to 11-year olds. Barriers to lipid screening and treatment included patients not returning for a fasting test, difficulty with patients adhering to diet and lifestyle recommendations, lack of comfort using statins, and lack of lipid specialists.

Given these barriers, how do we encourage healthy CV habits and increase access to preventive cardiology services? Behavior change is hard. The mountains of self-help books and guides on how to change habits published each year are testament to this. We have all had New Year’s resolutions that were quickly forgotten or ignored after a few months. There are times when it is difficult for us to accept advice even when we know the advice is good. The same goes for our patients.

As a cardiologist in the Preventive Cardiology Clinic at Nationwide Children’s Hospital, I am convinced that an approach that extends, educates and empowers a multidisciplinary and community-driven team is essential to impacting the greatest number of children. Our Preventive Cardiology team includes cardiologists, an advanced practice provider, nurses, dietitians and exercise physiologists. Each member plays a vital role in finding discrete steps that patients can take to help move towards healthier CV habits. Our dietitians in particular craft nutritional plans that are cholesterol and hypertension specific and our exercise physiologists provide guidance on safe ways for our patients to be more active.

Collaboration between divisions is key. The large and growing number of children with CV risk factors means that one service or group cannot diagnose and treat them all alone. We are proud to partner with our colleagues in nephrology to extend care for hypertensive patients and join with The Center for Healthy Weight and Nutrition for patients with multiple comorbidities. Partnership with primary care providers and community organizations are additional avenues to extend care to help diagnose and manage children with CV risk conditions. There is indeed strength in numbers.

It will take a concerted and sustained effort to turn the tide against the rise in CV risk factors in children, but it is possible. Preventing a heart attack or stroke is worth it. Just ask your friends and family members.

 

References

  1. Ference BA, Graham I, Tokgozoglu L, Catapano AL. Impact of lipids on cardiovascular health: JACC Health Promotion Series. Journal of the American College of Cardiologists. 2018;72:1141-1156.
  2. Luirink IK, Wiegman A, Kusters DM, Hof MH, Groothoff JW, de Groot E, Kastelein JJP, Hutten BA. 20-year follow-up of statins in children with familial hypercholesterolemia. New England Journal of Medicine. 2019;381:1547-1556.
  3. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents; National Heart, Lung, and Blood Institute. Summary report. Pediatrics. 2011;128 Suppl 5:S213-S256.
  4. de Ferranti SD, Rodday AM, Parsons SK, Cull WL, O’Connor KG, Daniels SR, Leslie LK. Cholesterol screening and treatment practices and preferences: A survey of United States pediatricians. Journal of Pediatrics. 2017;185:99-105 e2.

 

Image credit: Nationwide Children’s