Is the Atherosclerotic Cardiovascular Disease (ASCVD) risk assessment used in individuals aged 0-19, particularly those with high-risk conditions such as familial hypercholesterolemia, obesity, or a family history of early cardiovascular disease?

ASCVD Risk Assessment in Children and Adolescents (Ages 0-19)

The traditional ASCVD risk calculator (pooled cohort equations) is NOT used in children ages 0-19; however, cardiovascular risk assessment and stratification absolutely IS performed in this age group, particularly for high-risk conditions like familial hypercholesterolemia, diabetes, chronic kidney disease, and other conditions associated with accelerated atherosclerosis. 1

Why Risk Assessment Differs in Children

The standard ASCVD risk calculator was developed and validated for adults ages 40-79 years. 2 In pediatric populations, a different approach is needed because:

• Atherosclerosis begins in childhood with fatty streaks appearing in arteries as early as age 3, and atherosclerotic plaques developing in coronary arteries during adolescence 1
• Certain pediatric conditions cause dramatically accelerated atherosclerosis with clinical coronary events potentially occurring in childhood or very early adult life 1
• Traditional 10-year risk calculations are not applicable because children lack sufficient follow-up data for hard outcomes like myocardial infarction and stroke 1

Pediatric Risk Stratification System

Instead of the adult ASCVD calculator, the American Heart Association developed a three-tier risk stratification system specifically for children: 1

Tier I (High Risk) - Manifest coronary disease before age 30:

• Homozygous familial hypercholesterolemia
• Type 1 diabetes mellitus
• Chronic kidney disease/end-stage renal disease
• Post-heart transplantation
• Kawasaki disease with current coronary aneurysms 1

Tier II (Moderate Risk) - Accelerated atherosclerosis with pathophysiologic evidence:

• Heterozygous familial hypercholesterolemia
• Type 2 diabetes mellitus
• Kawasaki disease with regressed coronary aneurysms
• Chronic inflammatory disease 1

Tier III (At Risk) - High-risk setting with epidemiological evidence:

• Post-cancer treatment survivors
• Congenital heart disease
• Kawasaki disease without detected coronary involvement 1

Specific Assessment Approaches in Children

Universal Lipid Screening (Ages 9-11)

• The American College of Cardiology recommends non-fasting non-HDL cholesterol for ALL children between ages 9-11 years 3
• This timing is critical because lipid levels are relatively stable before puberty and atherosclerotic changes begin diverging between affected and unaffected children around age 10 3

Early Screening for High-Risk Children (As Early as Age 2)

• Children with family history of early cardiovascular disease or significant hypercholesterolemia should have lipid screening as early as age 2 years 4, 3
• Lipoprotein(a) testing should be measured as early as age 2 in these high-risk children 4
• Repeat Lp(a) testing at puberty (≥12 years) even if previous values were normal 4

Assessment of Subclinical Atherosclerosis

• Carotid intima-media thickness (cIMT) is used extensively to evaluate early subclinical disease in children with known risk factors 1
• Increased cIMT has been demonstrated in pediatric patients with familial hypercholesterolemia, type 1 diabetes, obesity, metabolic syndrome, chronic kidney disease, and other high-risk conditions 1

Risk Factor Assessment in Children

The comprehensive cardiovascular risk assessment in children includes: 1

• Fasting lipid profile (LDL, HDL, triglycerides, non-HDL cholesterol)
• Blood pressure measured on 3 separate occasions, interpreted for age/sex/height percentiles
• BMI with age/sex-specific percentiles
• Family history of early coronary artery disease in first-degree relatives (≤55 years in males, <65 years in females)
• Smoking history
• Physical activity assessment
• Fasting glucose and HbA1c when indicated
• Lipoprotein(a) in high-risk children 4

Treatment Thresholds by Risk Tier

The treatment goals are tier-specific and much more aggressive than general population recommendations: 1

Tier I (High Risk):

• LDL cholesterol goal: ≤100 mg/dL
• Blood pressure: ≤90th percentile for age/sex
• BMI: ≥85th percentile triggers intervention

Tier II (Moderate Risk):

• LDL cholesterol goal: ≤130 mg/dL
• Blood pressure: ≤95th percentile for age/sex/height
• BMI: ≥90th percentile triggers intervention

Tier III (At Risk):

• LDL cholesterol: ≥160 mg/dL triggers treatment
• Blood pressure: ≤95th percentile + 5 mm Hg
• BMI: ≥95th percentile triggers intervention

Pharmacological Treatment in Children

Familial Hypercholesterolemia:

• Pharmacological treatment should be offered at age 8-10 years with LDL-cholesterol >190 mg/dL on two occasions 1
• Consider treatment at age 8-10 years with LDL >160 mg/dL if multiple ASCVD risk factors or family history of premature ASCVD present 1
• Statins are the initial medication of choice that is approved for pediatric use 1
• Ezetimibe and bile acid sequestrants should be considered in addition to maximal tolerated statin dose 1

Elevated Lp(a) Management:

• When Lp(a) is elevated, intensify LDL-C reduction goals to approximately 50% from baseline, with target <100 mg/dL 4
• Markedly elevated Lp(a) (>75 nmol/L) combined with elevated LDL-C increases myocardial infarction risk 10-fold or higher 4
• Consider statin therapy at age ≥10 years if LDL-C remains ≥160 mg/dL after lifestyle modification, particularly with elevated Lp(a) 4

Common Pitfalls to Avoid

• Don't assume the adult ASCVD calculator applies to children - it was never validated in this population and uses entirely different methodology 1, 2
• Don't wait until adulthood to assess cardiovascular risk in high-risk children - parental history of ASCVD is a strong predictor, and children of parents with premature coronary disease show adverse cardiovascular profiles beginning in childhood 1
• Don't overlook the importance of family screening - when elevated Lp(a) or familial hypercholesterolemia is identified, perform cascade screening of first-, second-, and third-degree biological relatives 4
• Don't forget that atherosclerosis is a lifelong cumulative process - children with metabolic syndrome or parental history of premature ASCVD show early adverse changes in cIMT and vascular function 1