Background

In 2005, based on recommendations from experts convened in a national Thought Leaders Meeting, the National Heart, Lung, and Blood Institute (NHLBI), under the leadership of the Director Elizabeth G. Nabel, M.D., endorsed a new approach for guideline development. This new approach is characterized by a formal evidence review and an integrated format with the major cardiovascular (CV) risk factors addressed simultaneously in a single guideline document.

Atherosclerotic cardiovascular disease (CVD) remains the leading cause of death among North Americans. Although manifest disease in childhood and adolescence is rare, risk factors and risk behaviors that accelerate the development of atherosclerosis begin in childhood, and there is increasing evidence that risk reduction delays progression toward clinical disease. To address this health issue, the NHLBI appointed an Expert Panel to develop cardiovascular (CV) health and risk reduction guidelines for pediatric care providers based on the new approach, using a formal evidence review of this science with an integrated format addressing all the major CV risk factors simultaneously. This publication, Full Report of the Expert Panel on Integrated Guidelines for Pediatric Cardiovascular Health and Risk Reduction, is the result of the Expert Panel's work

Chaired by Dr. Stephen R. Daniels, the Expert Panel's goal was development of evidence-based guidelines addressing all of the major risk factors to assist pediatric care providers—pediatricians, family practitioners, nurses and nurse practitioners, physician assistants, and registered dietitians—in both the promotion of CV health and the identification and management of specific risk factors from infancy to young adulthood. The Expert Panel determined that a focus on CV risk reduction in children and adolescents addresses a disease process—atherosclerosis—in which the clinical endpoint of manifest CVD is much later in life. Therefore, the recommendations would need to address both the prevention of risk factor development—primordial prevention—and the prevention of future CVD by effective management of identified risk factors—primary prevention.

There have been no previous NHLBI-appointed expert panels that addressed multiple risk factors in children. Previous CV pediatric guidelines have addressed cholesterol (National Cholesterol Education Program:  Report of the Expert Panel on Blood Cholesterol Levels in Children and Adolescents (1992)) and blood pressure (The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents (2004)). The Expert Panel used these reports as a framework for development of the integrated format. A systematic review of the evidence was conducted to address a broad array of questions concerning the development, progression, and management of multiple CV risk factors extending from before birth to 21 years of age. This review required assessing all the evidence pertaining to the role of risk factors in childhood on the development and progression of atherosclerosis from childhood and adolescence to adulthood, as well as the body of evidence that addresses the impact of managing risk factors in childhood on the development and progression of atherosclerosis. Based on the assembled evidence, the Expert Panel developed graded, age-specific recommendations that are integrated across risk factors and across age groups.

In developing these comprehensive evidence-based Guidelines addressing all of the major risk factors, the panel has provided a practical approach to both the optimization of CV health and the management of identified risk factors throughout childhood and adolescence, a time when many health-behavior patterns develop and when risk reduction should have the greatest impact. These Guidelines should be of use to all those who provide health care to children to help them reduce future CV morbidity and mortality. By addressing the major population-based risk factors for CVD in children and adolescents, these guidelines will support pediatric care providers in optimizing CV health in infancy, early childhood, and adolescence-developmental periods when many health behavior patterns develop, risk factors may become evident, and risk reduction should have the greatest impact.

This Full Report of the Guidelines and the evidence tables will be available on the NHLBI Web site under "Pediatric Cardiovascular Risk Reduction Initiative" at http://www.nhlbi.nih.gov/guidelines/cvd_ped/index.htm. A Summary Report containing the conclusions of the evidence review and the recommendations has been prepared and is being published as a supplement in the December 2011 issue of the journal Pediatrics. The Summary Report is also available on the NHLBI Web site. Release of the Guidelines will be followed by dissemination and implementation activities.

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