Coronary artery disease risk factors, including systolic and diastolic blood pressures, serum lipoprotein levels, cigarette smoking, and body mass index, are directly related to the initiation and progression of atherosclerosis in children.^1,2

Risk factors that we know are important in adults are common in children and adolescents.³ Since 1990, the prevalence of tobacco use, obesity and sedentary lifestyle has steadily increased among U.S. children and adolescents. The incidence of smoking in youth has increased each year since 1991 and, every day, more than 3,000 adolescents start smoking. More than 20 percent of U.S. adolescents are currently overweight, representing a relative increase in prevalence of more than 50 percent since 1980. In addition, the number of high school students participating in physical education has steadily decreased. These declines in the health status of adolescents in the United States have important implications for future rates of cardiovascular disease. Cardiovascular disease will soon be the leading cause of premature death and disability worldwide.³

Because of their knowledge of family health, family physicians are in a unique position to screen for children at risk. In this issue of American Family Physician, Reginald Washington, M.D., an expert in cardiovascular disease in children, presents a practical, practice-based approach to assessing and managing risk factors for cardiovascular disease.⁴ He presents methods of incorporating risk assessments into children's health maintenance schedules and provides practical advice on managing risk factors. These recommendations are consistent with national guidelines for reducing future premature cardiovascular disease.

Controversy remains, however, on screening for hyperlipidemia in children and the medical treatment of high blood cholesterol levels and blood pressure in this age group.^5,6 Can the treatment of risk factors wait until adulthood? The pathologic studies suggest that atherosclerosis is diffuse and advanced as early as adolescence.^1,2 Expert panels have concluded that adolescents who have blood pressure or low-density lipoprotein (LDL) cholesterol levels greater than the 90th percentile should receive medication if they are not responding to lifestyle changes, based on the risk associated with prolonged extreme elevations of blood pressure or LDL cholesterol levels.^5,7

Nevertheless, it is difficult to extrapolate health care recommendations for children from the results of clinical trials performed in adults. Long-term trials of risk factor modification in children to prevent future cardiovascular events are not available, nor are they likely to be, because of the large sample sizes, expense and length of time required for meaningful results.

Research studies other than trials that assess morbidity and mortality could answer important questions and guide clinical decisions. We need new methods of promoting behavior change or preventing the initiation of unhealthy behaviors. Innovative ways of demonstrating whether medical treatment of high blood pressure or cholesterol levels reduces the incidence of atherosclerosis and its progression—such as noninvasive methods of measuring atherosclerosis—could assess whether medical treatment is beneficial in high-risk children and adolescents.

Primary prevention of atherosclerosis is important because over 40 percent of cardiovascular events occur in persons under 65 years of age, and nearly 50 percent of these events are fatal.³ The issue remains at what age do we start medical treatment? It is reasonable to make every effort to ensure that our children avoid tobacco, be physically active and have a healthy diet. It is also reasonable to treat extreme risk that is highly likely to result in premature cardiovascular disease. The conservative recommendations of Washington⁴ and the National Institutes of Health⁵ serve as appropriate guidelines for health maintenance.