Arq Bras Cardiol abc Arquivos Brasileiros de Cardiologia Arq. Bras. Cardiol. 0066-782X 1678-4170 Sociedade Brasileira de Cardiologia - SBC RbFtNGzXKkdbXbrJnXVKmXq S0066-782X2019000200152 10.5935/abc.20190016 Short Editorial The Importance of Identifying Risk Factors in Childhood and Adolescence 0000-0002-2881-1820 Chacra Ana Paula Marte Universidade de São Paulo Faculdade de Medicina Hospital das Clínicas São Paulo SP Brazil Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brazil Mailing Address: Ana Paula Marte Chacra, Rua Oscar de Almeida, 240, Morumbi, São Paulo, SP - Brazil. E-mail: anapmchacra@cardiol.br, anapmchacra@uol.com.br 02 2019 112 2 152 153 This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Keywords Dyslipidemias Obesity Overweight Adolescent Cholesterol LDL-C Triglycerides Risk Factors Atherosclerosis

The study "Dyslipidemia in Adolescents Seen in a University Hospital in the city of Rio de Janeiro/Brazil: Prevalence and Association" showed a high prevalence of obesity (53%) followed by overweight (25.2%) in adolescents. The obese group had a predominance of low HDL-c besides the positive association of body mass index (BMI) and abdominal circumference with triglyceride values.1 These date are fundamental and warn of the importance of early assessment of risk factors.

Elevated triglycerides and low HDL-c are strongly linked to obesity, especially in youth2 and early exposure to that unfavourable metabolic profile will contribute to a higher cardiovascular risk.3

Evidences have shown that atherosclerosis begins in childhood and it is associated with early presence of established risk factors for cardiovascular disease. The progression of atherosclerotic process depends on the time of exposure beyond the interaction between conventional, genetics and environmental risk factors.4,5

Despite the early onset of atherogenesis, children and adolescents do not develop clinic manifestations of coronary heart disease, since cardiovascular outcomes depend on prolonged exposure to risk factors. Even so, few longitudinal studies have linked childhood risk factors to adult cardiovascular disease.

Twig et al.6 demonstrated association between higher BMI during adolescence with increased cardiovascular mortality in adulthood throughout 40 years of follow-up.6 Increased in BMI and triglyceride level was predictive of cardiovascular event in young adulthood, whereas LDL-c levels did not.7

Measurements of carotid intima-media thickness (cIMT) by non-invasive imaging techniques provide a surrogate endpoint to assess early atherosclerosis.8 Studies have shown that childhood clustering of risk factors are predictive of adult cIMT.9

In the study “International Childhood Cardiovascular Cohort (i3C)", Koskinen et al.10 demonstrated that obesity, hypertension, and dyslipidemia were predictors of high cIMT in adults.10 They found that obesity in children was the most prevalent risk factor associated with high cIMT in adult, increasing the risk by 3.7 times.10 Using risk prediction models, when it added the lipid profile to obesity and hypertension, there was a modest improvement in the risk discrimination for increased cIMT in adulthood (area under the curve increased from 0.698-0.717). It may be due to a weak relationship between LDL-c levels and obesity since obesity interferes minimally with LDL-c levels10 except where obesity-related metabolic changes unmask an underlying genetic dyslipidemia. In the present cross-sectional study1 obesity seems to be the driver of the lipid changes as prevalence of low HDL-c and association of abdominal adiposity with triglycerides levels, without changes in LDL-c values.1 Despite these findings, high LDL-c is a well-established risk factor for atherosclerosis as observed in familial hypercholesterolemia, and early detection allows the initiation of pharmacological therapy even in the children.11

The present study reinforces that current obesity is a growing epidemic.1 The Universal screening would allow for earlier diagnosis and intervention for children with dyslipidemia secondary to lifestyle or genetic factors.12

Short Editorial related to the article: Dyslipidemia in Adolescents Seen in a University Hospital in the city of Rio de Janeiro/Brazil: Prevalence and Association

 References 1 Vizentin NP, Cardoso PMS, Maia CAG, Alves IP, Aranha GL, Giannini DT. Dyslipidemia in adolescents seen in a university hospital in the city of Rio de Janeiro/Brazil: prevalence and association. Arq Bras Cardiol. 2019; 112(2):147-151 Vizentin NP Cardoso PMS Maia CAG Alves IP Aranha GL Giannini DT Dyslipidemia in adolescents seen in a university hospital in the city of Rio de Janeiro/Brazil: prevalence and association Arq Bras Cardiol 2019 112 2 147 151 2 Elmaoğulları S, Tepe D, Uçaktürk SA, Karaca Kara F, Demirel F. Prevalence of dyslipidemia and associated factors in obese children and adolescents. J Clin Res Pediatr Endocrinol. 2015;7(3):228-34. Elmaoğulları S Tepe D Uçaktürk SA Karaca Kara F Demirel F Prevalence of dyslipidemia and associated factors in obese children and adolescents J Clin Res Pediatr Endocrinol 2015 7 3 228 234 3 Skinner AC, Perrin EM, Moss LA, Skelton JA. Cardiometabolic risks and severity of obesity in children and young adult. N Engl J Med. 2015;373(4):1307-17. Skinner AC Perrin EM Moss LA Skelton JA Cardiometabolic risks and severity of obesity in children and young adult N Engl J Med 2015 373 4 1307 1317 4 Berenson GS, Wattigney WA, Tracy RE, Newman WP 3rd,et al. Atherosclerosis of the aorta and coronary arteries and cardiovascular risk factors in persons aged 6 to 30 years and studied at necropsy (The Bogalusa Heart Study). Am J Cardiol. 1992; 70(9):851-8. Berenson GS Wattigney WA Tracy RE Newman WP 3rd Atherosclerosis of the aorta and coronary arteries and cardiovascular risk factors in persons aged 6 to 30 years and studied at necropsy (The Bogalusa Heart Study) Am J Cardiol 1992 70 9 851 858 5 Wissler RW. USA Multicenter Study of the pathobiology of atherosclerosis in youth. Ann N Y Acad Sci. 1991;623:26-39. Wissler RW USA Multicenter Study of the pathobiology of atherosclerosis in youth Ann N Y Acad Sci 1991 623 26 39 6 Twig G, Yaniv G, Levine H, Leiba A, Goldberger N, Derazne E, et al. Body-mass index in 2.3 million adolescents and cardiovascular death in adulthood. N Engl J Med. 2016;374(25):2430-40. Twig G Yaniv G Levine H Leiba A Goldberger N Derazne E Body-mass index in 2.3 million adolescents and cardiovascular death in adulthood N Engl J Med 2016 374 25 2430 2440 7 Morrison JA, Glueck CJ, Horn PS, Yeramanemi S, Wang P. Pediatric triglycerides predict cardiovascular disease events in the fourth to fifth decade of life. Metabolism. 2009;58(9):1277-84. Morrison JA Glueck CJ Horn PS Yeramanemi S Wang P Pediatric triglycerides predict cardiovascular disease events in the fourth to fifth decade of life Metabolism 2009 58 9 1277 1284 8 Lorenz MW, Markus HS, Bots ML, Rosvall M, Sitzer M. Prediction of clinical cardiovascular events with carotid intima-media thickness: a systematic review and meta-analysis. Circulation. 2007;115(4):459-67. Lorenz MW Markus HS Bots ML Rosvall M Sitzer M Prediction of clinical cardiovascular events with carotid intima-media thickness: a systematic review and meta-analysis Circulation 2007 115 4 459 467 9 Li S, Chen W, Srinivesan SR, Bond MG, Tang R, Urbina EM, et al. Childhood cardiovascular risk factors and carotid vascular changes in adulthood: the Bogalusa Heart Study. JAMA. 2003;290(17):2271-6. Li S Chen W Srinivesan SR Bond MG Tang R Urbina EM Childhood cardiovascular risk factors and carotid vascular changes in adulthood: the Bogalusa Heart Stud JAMA 2003 290 17 2271 2276 10 Koskinen J, Juonala M, Dwyer T, Venn A, Thomson R, Bazzano L, et al. Impact of lipid measurements in youth in addition to conventional clinic-based risk factors on predicting preclinical atherosclerosis in adulthood: International Childhood Cardiovascular Cohort Consortium. Circulation. 2018;137(12):1246-55. Koskinen J Juonala M Dwyer T Venn A Thomson R Bazzano L Impact of lipid measurements in youth in addition to conventional clinic-based risk factors on predicting preclinical atherosclerosis in adulthood: International Childhood Cardiovascular Cohort Consortium Circulation 2018 137 12 1246 1255 11 Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents; National Heart, Lung, and Blood Institute. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: summary report. Pediatrics. 2011;128(Suppl 5):S213-S256. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents National Heart, Lung, and Blood Institute Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: summary report Pediatrics 2011 128 Suppl 5 S213 S256 12 Kwiterovich PO, Gidding SS. Universal screening of cholesterol in children. Clin Cardiol. 2012;35(11):662-4. Kwiterovich PO Gidding SS Universal screening of cholesterol in children Clin Cardiol 2012 35 11 662 664 Minieditorial A Importância da Identificação de Fatores de Risco na Infância e Adolescência 0000-0002-2881-1820 Chacra Ana Paula Marte Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil Correspondência: Ana Paula Marte Chacra, Rua Oscar de Almeida, 240, Morumbi, São Paulo, SP - Brasil. E-mail: anapmchacra@cardiol.br, anapmchacra@uol.com.br Palavras-chave Dislipidemias Obesidade Sobrepeso Adolescente Colesterol LDL-C Triglicérides Fatores de Risco Aterosclerose

O estudo “Dislipidemia em Adolescentes Atendidos em um Hospital Universitário no Rio de Janeiro/Brasil: Prevalência e Associação” demonstrou alta prevalência de obesidade (53%) seguida de sobrepeso (25,2%) em adolescentes. O grupo obeso apresentou predominância de HDL-c baixo e associação positiva entre índice de massa corporal (IMC), circunferência abdominal e valores de triglicérides.1 Esses dados são fundamentais e alertam para a importância da avaliação precoce dos fatores de risco.

A obesidade está associada a níveis de triglicérides elevados e HDL-C baixo, especialmente nos jovens,2 onde a exposição precoce a esse perfil metabólico desfavorável, contribuirá para um maior risco cardiovascular.3

Evidências demonstram que a aterosclerose começa na infância e está correlacionada à presença precoce de fatores de risco para doença cariovascular. A progressão do processo aterosclerótico depende do tempo de exposição, além da interação entre fatores de risco convencionais, genéticos e ambientais.4,5

Apesar do início prematuro da aterogênese, crianças e adolescentes não desenvolvem manifestações clínicas da doença arterial coronária, uma vez que os desfechos cardiovasculares dependem da exposição prolongada aos fatores de risco. Mesmo assim, alguns estudos longitudinais associaram os fatores de risco na infância à doença cardiovascular em adultos.

Twig et al.,6 demonstraram associação entre IMC durante a adolescência, com aumento da mortalidade cardiovascular na idade adulta, ao longo de 40 anos de seguimento.6 O aumento do IMC e dos níveis de triglicérides foram preditores de eventos cardiovasculares nos adultos jovens, não sendo observada associação com níveis de LDL-c.7

As medidas da espessura médio -intimal de carótidas (EMI) são consideradas marcadores substitutos de desfechos cardiovasculares e utilizadas para detecção de aterosclerose precoce.8 Estudos prévios demonstraram que o agrupamento de fatores de risco, na infância, são preditivos do aumento da EMI de carótidas, em adultos.9

No estudo “International Childhood Cardiovascular Cohort (i3C)”, Koskinen et al.,10 demonstraram que obesidade, hipertensão e dislipidemia foram preditores do aumento da EMI de carótida em adultos.10 Observaram que a obesidade em crianças foi o fator de risco mais prevalente associado ao maior EMI de carótida em adultos, aumentando o risco em 3,7 vezes.10 Utilizando modelos de predição de risco, ao adicionar-se o perfil lipídico à obesidade e à hipertensão, houve melhora modesta na discriminação de risco para aumento da EMI da carótida na idade adulta (a área sob a curva aumentou de 0,698-0,717). Esse resultado pode ser consequente a uma fraca relação entre os níveis de LDL-c e obesidade, uma vez que a obesidade interfere minimamente com os níveis de LDL-c,10 exceto quando alterações metabólicas relacionadas à obesidade mascaram uma dislipidemia genética subjacente.

No presente estudo transversal,1 a obesidade parece ser a propulsora das alterações lipídicas, como a prevalência de HDL-c baixo e a associação da adiposidade abdominal com os níveis de triglicérides, sem alterações nos valores de LDL-c.1 A despeito desses achados, o LDL-c elevado é um fator de risco bem estabelecido para a aterosclerose, como observado na hipercolesterolemia familiar, e a detecção precoce permite o início da terapia farmacológica mesmo nas crianças.11

O presente estudo reforça que a obesidade atual é uma epidemia crescente.1 A triagem universal permitiria o diagnóstico e a intervenção precoces em crianças com dislipidemia secundária a fatores genéticos ou de estilo de vida.12

Minieditorial referente ao artigo: Dislipidemia em Adolescentes Atendidos em um Hospital Universitário no Rio de Janeiro/Brasil: Prevalência e Associação