What cardiac interventions are required in the management of hypercholesterolemia in children?

From the Guidelines

Cardiac interventions for managing hypercholesterolemia in children primarily focus on lifestyle modifications first, with pharmacotherapy reserved for higher-risk cases. Initial management should emphasize a heart-healthy diet low in saturated fats and cholesterol, regular physical activity (at least 60 minutes daily), and weight management if needed, as recommended by the American Heart Association 1. Pharmacological treatment is typically considered for children aged 10 years or older with LDL-C levels ≥190 mg/dL despite lifestyle changes, or ≥160 mg/dL with family history of premature cardiovascular disease or multiple risk factors, according to the guidelines from the American Heart Association 1. Statins are the first-line medication, starting with low doses such as atorvastatin 10 mg daily or rosuvastatin 5 mg daily, with gradual titration based on response. Bile acid sequestrants (cholestyramine 4 g daily) may be used in younger children or as adjunct therapy, and ezetimibe (10 mg daily) can be added for those not achieving target LDL-C levels, as suggested by the expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents 1. Regular monitoring of lipid profiles, liver function, and muscle enzymes is essential during pharmacotherapy, and PCSK9 inhibitors are rarely used in pediatric patients but may be considered in severe familial hypercholesterolemia cases. Early intervention is crucial as childhood hypercholesterolemia often persists into adulthood, increasing the risk of premature atherosclerosis and cardiovascular disease, highlighting the importance of following the most recent guidelines from reputable sources such as the American Heart Association 1.

Some key points to consider in the management of hypercholesterolemia in children include:

• The importance of lifestyle modifications as the first line of treatment
• The use of statins as the first-line medication for pharmacological treatment
• The need for regular monitoring of lipid profiles, liver function, and muscle enzymes during pharmacotherapy
• The consideration of PCSK9 inhibitors in severe familial hypercholesterolemia cases
• The importance of early intervention to prevent the persistence of hypercholesterolemia into adulthood and the associated increased risk of premature atherosclerosis and cardiovascular disease.

Overall, the management of hypercholesterolemia in children requires a comprehensive approach that includes lifestyle modifications, pharmacological treatment, and regular monitoring, with the goal of reducing the risk of premature atherosclerosis and cardiovascular disease.

From the FDA Drug Label

As an adjunct to diet to reduce low-density lipoprotein cholesterol (LDL-C) in: Adults and pediatric patients aged 10 years and older with heterozygous familial hypercholesterolemia (HeFH). As an adjunct to other LDL-C-lowering therapies, or alone if such treatments are unavailable, to reduce LDL-C in adults and pediatric patients aged 10 years and older with homozygous familial hypercholesterolemia (HoFH)

The required cardiac interventions in the management of hypercholesterolemia in children include:

• LDL-C reduction: Using medications such as atorvastatin 2 or simvastatin 3 as an adjunct to diet to reduce LDL-C levels in pediatric patients aged 10 years and older with HeFH or HoFH.
• Combination therapy: Using ezetimibe 4 in combination with a statin as an adjunct to diet to reduce elevated LDL-C in pediatric patients 10 years of age and older with HeFH.
• Dietary modifications: As an adjunct to pharmacological therapy to reduce LDL-C levels. No specific cardiac interventions such as revascularization procedures or other invasive cardiac procedures are mentioned in the provided drug labels for the management of hypercholesterolemia in children.

From the Research

Cardiac Interventions for Hypercholesterolaemia in Children

The management of hypercholesterolaemia in children involves a combination of lifestyle modifications and pharmacological interventions. The primary goal is to prevent the development of atherosclerosis and reduce the risk of cardiovascular disease.

• Lifestyle Modifications: Healthy lifestyle habits, including a prudent low-fat diet, are essential in managing hypercholesterolaemia in children 5. The Mediterranean diet is recommended due to its benefits in reducing cardiovascular risk.
• Pharmacological Interventions: Statins are the cornerstone of drug therapy for hypercholesterolaemia in children, approved for use in the USA and Europe 5, 6. Ezetimibe or bile acid sequestrants may be required to attain LDL-C goals in some patients 5, 7.
• LDL-C Targets: The management target level for LDL-C is less than 140 mg/dL 8. If the level of LDL-C remains above 180 mg/dL, drug therapy should be considered at the age of 10 8.
• Special Considerations: For homozygous familial hypercholesterolaemia (HoFH), lipoprotein apheresis or plasmapheresis may be necessary to lower cholesterol levels 7. New drugs, such as lomitapide and mipomersen, have been licensed for HoFH, but evidence of safety in children is lacking 7.
• Evaluation and Monitoring: Evaluation of atherosclerosis should be started using non-invasive techniques, such as ultrasound 8. Regular monitoring of LDL-C levels and cardiovascular risk factors is essential to adjust treatment strategies as needed.

Key Considerations

• Early identification of children with severe hypercholesterolaemia or familial hypercholesterolaemia is crucial to prevent atherosclerosis and cardiovascular disease 5, 8.
• A family history of premature cardiovascular events or hypercholesterolaemia is an important factor in diagnosing and managing hypercholesterolaemia in children 5, 9.
• Increasing awareness of familial hypercholesterolaemia is essential to reduce the burden of acute coronary syndrome and cardiovascular mortality 9.