While the incidence of childhood cardiovascular disease (CVD) is rare, certain exposures in childhood can have a striking impact on adult cardiovascular health. “None of us enter adulthood with a clean slate of cardiovascular health,” says Bradley Marino, MD, MBA, Department Chair of Pediatric Cardiology in Cleveland Clinic Children’s.
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Progressive loss of cardiovascular health begins in childhood. By age 12, one-third of children in the U.S. have lost ideal BMI status, putting them at risk for future cardiovascular decline. 1
Understanding the strongest associations between childhood risk factors and adult CVD may help providers better manage early life care and potentially prevent future adverse cardiac events.
Dr. Marino co-authored an article published in the Journal of Pediatrics that broadly examines current literature and assesses the strength of the evidence linking various exposures in childhood to adult risk, while also highlighting gaps in the research.
The team conducted a systematic review of 210 articles published through 2018 that aligned with the following criteria: a longitudinal study in a community-based population with a primary childhood exposure linked to subclinical or clinical CVD in adulthood.
Identifying associations in the literature, and a call for more research
Findings revealed that the majority of publications identified show a positive association between childhood adiposity, blood pressure and cholesterol, respectively, to subclinical and clinical CVD in adulthood. The authors also conclude that robust evidence links low birth weight, lower socioeconomic status and psychosocial adversity to adult clinical CVD (although limited evidence was available to support its translation to subclinical CVD).
Dr. Marino says these findings weren’t completely surprising given what is known about those risk factors already, but it does reinforce the need to develop early interventions for patients exhibiting early risk for CVD.
The study also highlights prominent gaps in contemporary research, as considerably fewer studies examined connections between breastfeeding, glycemic control, tobacco exposure, physical activity and diet in childhood and their respective associations with the onset of clinical and subclinical CVD.
Additionally, the authors signal a need to recruit diverse patient populations into future research cohorts to better understand complex racial and ethnic differences involved in the development and progression of clinical and subclinical CVD.
Life course models in the context of cardiovascular health
Dr. Marino notes that three life course models may explain the development of CVD and help guide interventions.
Chain-of-risk model. This model theorizes that adult CVD is largely incurred from adult exposures and behaviors. It affirms that pediatric exposures elevate risk but are not directly related to adverse outcomes. “From a practical perspective, this model is the most encouraging,” Dr. Marino says. “It supports early interventions that may lead to good long-term outcomes.”
Accumulation of risk model. This model highlights the sequentiality of risk across the lifespan beginning with the fetal environment, early childhood and adolescent risks, which have an accumulative effect into adulthood. “If this model is accurate, then what we see in childhood is unbelievably important,” explains Dr. Marino.
Critical/sensitive period model. The third model underscores the importance of a critical exposure point in the life course and its disproportionate impact, versus the same exposure during a different time in the life course. “This model presupposes that certain events in critical exposure windows – like adiposity as an adolescent or factors in the fetal environment, as examples – may have a critical impact,” he says.
Key research and clinical takeaways
This research highlights the importance of centering future investigations on high-risk populations, being intentional about representation and diversity in research cohorts, and looking beyond traditional CVD domains, such as adiposity, hypertension and hypercholesterolemia.
Dr. Marino says more research is needed to investigate quality diet, physical activity, tobacco exposure, and the context of a child’s psychosocial environment.
Clinical collaborations between the adult and pediatric cardiology departments at Cleveland Clinic and Cleveland Clinic Children’s enable a strong continuity of care for pediatric patients who may be at risk for developing CVD. Joint initiatives like the newly launched Pediatric and Adult Congenital Heart Center make this possible for congenital CVD, as well.
“There is still much to parse out, but studies like this add clarity to an important conversation about how tailored prevention programs and interventions in childhood can potentially alter the trajectory of a patient’s cardiovascular health.”
- Benjamin EJ, Blaha MJ, Chiuve SE, et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics-2017 update: a report from the American Heart Association [published correction appears in Circulation. 2017;135(10):e646; and 2017;136(10):e196]. Circulation. 2017;135(10):e146–e603