Towards A Road Map for Best Practices in Pediatric Preventive Cardiology

The field of pediatric preventive cardiology can be divided into three eras. From the 1950s to the early 1980s, it was demonstrated, mostly through epidemiologic and pathologic research, that atherosclerosis begins at a young age, that risk factors for atherosclerosis are present and related to diet, obesity, and other health behaviors, and people who have cardiovascular events in early adulthood typically have risk factors present in youth. Thereafter, the second era began. It was demonstrated that pediatric risk factors are related to early atherosclerosis and to atherosclerosis measured in young adulthood, that high risk conditions like familial hypercholesterolemia, diabetes and the combined presence of multiple risk factors were associated with early events, and that pediatric clinical trials including diet intervention and pharmacologic lowering of blood pressure and cholesterol were effective for risk factor control. Pioneering pediatric prevention clinics were established and provided models for care. Guidelines for risk factor management in childhood were published, culminating in the publication of the 2011 Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents.

 We are now firmly in the third era, where the need for public health initiatives to control cardiovascular risk factors early in life is well understood, it is recognized that early intervention should occur in situations where there is high risk for cardiovascular events early in life, and evidence gaps that remain in the field of pediatric preventive cardiology need to be closed to tighten the evidence base for intervention. In full recognition of this, Perak et al have published a landmark study, "Towards A Road Map for Best Practices in Pediatric Preventive Cardiology."¹ The investigators surveyed pediatric cardiology program directors and preventive pediatric cardiologists with a goal of understanding the current state of care and barriers to success. They conclude with a call to action to assist with standardization of practice, identify human resources needed to support high quality programs, to secure funding for programs, to improve training. and to improve research. The information provided in this document can be used by pediatric cardiology programs, pediatric departments, health care systems, professional societies, and government and foundation funders to support the field through infrastructure investment and research funding.

 While this science advisory provides important information for the field of cardiology, prevention of future heart disease depends on collaboration across other medical disciplines. Endocrinologists worldwide are the primary specialty managing lipid disorders and also care for children with diabetes. Nephrologists manage hypertension. Gastroenterologists have an interest in nutrition and lipid metabolism. Geneticists are increasingly important as inherited causes of risk are better understood. A broad group of specialists provide obesity care. Lipidology as an independent specialty is gaining traction. Public health and epidemiology will be important in risk factor control and monitoring of trends in risk factors and events. Most important, without primary care providers recognizing risk, specialists cannot receive referrals. Therefore, an additional challenge to preventive cardiology is to create inter-disciplinary programs that provide care efficiently, without increasing health care costs.

 An important gap in this report is that it does not include the perspectives of private practice physicians. Many more patients are seen in private practice settings than in academic institutions. Private pediatric cardiologists may not receive adequate reimbursement for preventive care or have support from nutrition, genetic counsellors, psychologists, or pharmacologists. Primary care providers may not be able to prioritize preventive cardiology screening in the presence of time constraints on health maintenance visits and competing, more urgent patient concerns, such as acute mental health issues. Family medicine providers tend to follow United States Preventive Services Task Force recommendations; the presence of incomplete recommendations for pediatric blood pressure and cholesterol screening will impede early risk recognition by those providers. How to prioritize preventive cardiology care for children in private practice will be a major challenge for the field in the coming years.

 Highlighted by Perak et al is the need for clinical trials to close crucial evidence gaps. The absence of clinical trials of three to five years duration, particularly in regard to hypertension and severe elevation of cholesterol, with meaningful clinical and safety end points is a key reason for the incomplete recommendations provided by the United States Preventive Services Task Force. Clinical trials are also needed in high-risk scenarios, including children with diabetes and chronic kidney disease, where risk factor control at a young age might substantially improve outcomes from premature heart disease. Without these clinical trials, the benefits of early prevention will not be understood or appreciated by providers without the expertise of those trained in preventive cardiology.

 How best to accomplish the ambitious plan for codifying pediatric preventive cardiology care? Implementation science may provide the answer. The survey results presented by Perak et al are an important first step on this path, identifying not only key barriers to care, but also facilitators. Building on the results of this survey, pediatric cardiologists and key stakeholders including patients, health care system leadership, primary care providers, and support personnel should participate in implementation science research, to design efficient and cost-effective pediatric preventive cardiology care models that are acceptable to providers and can be generalized beyond the academic setting into primary care and public health.

Over the past 70 or so years, pediatric preventive cardiology has made substantial progress in the prevention of acquired heart disease later in life. Moving from epidemiologic and pathologic observation, to acquiring evidence for the value of early prevention, and to establishing effective public health and clinical strategies for risk factor control. The field is ready to confront the challenges of standardizing care. Recommendations, as outlined by Perak et al, is a key first step in this process. Hopefully, this third era of pediatric prevention will make heart disease prevention practices normative for both public health and clinical communities.