Public Policy to Promote Healthy Cardiovascular Lifestyles in Children.

Health policy is an important component of prevention of cardiovascular disease (CVD) and promotion of health in childhood and adolescence, when major health behaviours are formed. Development of CVD-related health policy begins with continuous systematic collection, analysis, and interpretation of health-related data to establish the baseline prevalence of CV risk factors and behaviours. These findings allow identification of problems, initiation of focused research, and development of evidence-based interventions. Ultimately, these results inform development and implementation of population-level policies. This review focuses on CVD health-promotion policies in North American youth, for whom health surveillance is an ongoing part of public health policy, providing direct, objective, measurements of growth, lipids, blood pressure, physical activity and tobacco exposure for development of CV health research and policy. When national surveillance data identified significant risk of CVD in youth in the 1970s, major pediatric epidemiologic studies established the strong association between these risk factors and behaviours in childhood and the initiation and progression of atherosclerosis. This knowledge promoted development of the targeted public policies, which are reviewed in this paper. Public policy can directly and positively address cardiovascular health promotion in youth; the effective approach to smoking cessation exemplifies this. For more complex risk factors and behaviours, health policy can be a significant element in a comprehensive CV health promotion program.

Distinguishing cardiac syncope from vasovagal syncope in a referral population.

OBJECTIVE: To identify characteristics that distinguish cardiac from vasovagal syncope. STUDY DESIGN: We compared characteristics of patients ≤18 years of age with vasovagal and cardiac syncope. Vasovagal syncope subjects represented all patients presenting to outpatient cardiology during a 1-year period for initial evaluation of syncope diagnosed with vasovagal syncope. Cardiac patients were all patients identified by review of diagnoses known to include syncope as a symptom who presented with syncope to the emergency department or inpatient or outpatient cardiology during a 10-year period identified with cardiac etiology. RESULTS: There were 89 patients 4-18 years of age with vasovagal syncope and 17 patients 4 months to 17 years of age with cardiac syncope. When we compared patients with cardiac syncope to those with vasovagal syncope, we found that syncope surrounding activity was present in 65% vs 18% (P < .001), family history of cardiac disease or sudden cardiac death was identified in 41% vs 25% (P = .2), abnormal findings on the physical examination supporting cardiac diagnosis were present in 29% vs 0% (P < .001), and abnormal findings on electrocardiograms were found in 76% vs 0%, respectively (P < .001). Screening for cardiac disease using any 1 of these 4 characteristics had a sensitivity of 100% and specificity of 60%. Using this screening rule, we found that 60% of patients with vasovagal syncope would not have been referred to cardiology. CONCLUSIONS: Cardiac and vasovagal syncope have dramatic differences in presentation. A screening rule that uses historic features, physical examination findings, and electrocardiogram will accurately separate patients requiring further evaluation for cardiac etiology from those with vasovagal syncope in whom cardiology referral is unnecessary.

Hypertensive changes within the aortic arch of infants and children with isolated coarctation.

BACKGROUND: Despite repair, a significant proportion of patients with coarctation of the aorta (CoA) present with late hypertension. Increased gene expression of aortic wall collagen and vascular smooth muscle cell markers occurs in the presence of hypertension. Before repair, a patent ductus arteriosus (PDA) limits hypertension proximal to the coarctation. We hypothesize that preoperative collagen and vascular smooth muscle expression from the aortic arch in children is variable, depending on the presence or absence of a PDA. METHODS: We analyzed the expression patterns of collagen and vascular smooth muscle cell markers in 25 children with CoA using a quantitative polymerase chain reaction. Aortic arch tissue proximal to the CoA was normalized to descending aortic tissue distal to the coarctation. Collagen-I, transforming growth factor-ß, elastin, and calponin were analyzed. RESULTS: At repair, 19 patients were aged younger than 3 months (14 with a PDA, 5 with a ligamentum arteriosum), and the remaining 6 were older than 1 year. There was no difference in age or weight between infants with or without a PDA. Infants without a PDA had the greatest difference in collagen-I expression compared with infants with a PDA (7.0 ± 1.6-fold vs 0.8 ± 1.1-fold, p = 0.01). Expression of transforming growth factor-ß (4.3 ± 1.4 vs 2.6 ± 2.3, p = 0.01) and calponin (3.7 ± 0.7 vs 0.6 ± 1.1, p = 0.05) was lower from infants with vs without a PDA. CONCLUSIONS: Our findings provide evidence of preoperative changes in the aortic arch before repair, particularly in the absence of a PDA.

Cardiovascular risk reduction in high-risk pediatric patients: a scientific statement from the American Heart Association Expert Panel on Population and Prevention Science; the Councils on Cardiovascular Disease in the Young, Epidemiology and Prevention, Nutrition, Physical Activity and Metabolism, High Blood Pressure Research, Cardiovascular Nursing, and the Kidney in Heart Disease; and the Interdisciplinary Working Group on Quality of Care and Outcomes Research.

Although for most children the process of atherosclerosis is subclinical, dramatically accelerated atherosclerosis occurs in some pediatric disease states, with clinical coronary events occurring in childhood and very early adult life. As with most scientific statements about children and the future risk for cardiovascular disease, there are no randomized trials documenting the effects of risk reduction on hard clinical outcomes. A growing body of literature, however, identifies the importance of premature cardiovascular disease in the course of certain pediatric diagnoses and addresses the response to risk factor reduction. For this scientific statement, a panel of experts reviewed what is known about very premature cardiovascular disease in 8 high-risk pediatric diagnoses and, from the science base, developed practical recommendations for management of cardiovascular risk.

Cardiovascular risk reduction in high-risk pediatric patients: a scientific statement from the American Heart Association Expert Panel on Population and Prevention Science; the Councils on Cardiovascular Disease in the Young, Epidemiology and Prevention, Nutrition, Physical Activity and Metabolism, High Blood Pressure Research, Cardiovascular Nursing, and the Kidney in Heart Disease; and the Interdisciplinary Working Group on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics.

Although for most children the process of atherosclerosis is subclinical, dramatically accelerated atherosclerosis occurs in some pediatric disease states, with clinical coronary events occurring in childhood and very early adult life. As with most scientific statements about children and the future risk for cardiovascular disease, there are no randomized trials documenting the effects of risk reduction on hard clinical outcomes. A growing body of literature, however, identifies the importance of premature cardiovascular disease in the course of certain pediatric diagnoses and addresses the response to risk factor reduction. For this scientific statement, a panel of experts reviewed what is known about very premature cardiovascular disease in 8 high-risk pediatric diagnoses and, from the science base, developed practical recommendations for management of cardiovascular risk.