Management of CV Risk Factors in Youth

Wednesday, October 31, 2018, 12:00 AM - Thursday, October 31, 2019, 12:00 AM

Pediatric Grand Rounds

1. Recall current guidelines for screening for dyslipidemia in youth;
2. Define HTN in youth from 2017 AAP CPG; and
3. Recall lifestyle modifications for high cholesterol and high BP in youth.

Accreditation Statement

In support of improving patient care, Indiana University School of Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physicians

Indiana University School of Medicine designates this enduring activity for a maximum of 1.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

References for this presentation: 1. Jiang X, Srinivasan SR, Urbina EM, Berenson GS.  Hyperdynamic Circulation and Cardiovascular Risk in Children and Adolescents:  The Bogalusa Heart Study, Circulation, 1995;91:1101-1106. 2. Urbina EM, Gidding SS, Bao W, Pickoff AS, Berdussis K, Berenson GS.  Effect of Body Size and Blood Pressure on Left Ventricular Growth in Children and Young Adults: The Bogalusa Heart Study, Circulation 1995;91:2400-2406. This was one of the first longitudinal studies of LV size in youth ever conducted.  It demonstrated that in addition to BP, change in weight was an important predictor of future LV mass.  As co-PI on the grant from which these data were derived, I personnally read all the echos and supervised the data entry and statistical support team.  Science Citation Index indicates this paper has been cited 156 times including:  2012=3, 2013=12, 2014=8, 2015=7, 2016=6, 2017=6.3. Urbina EM, Brinton TJ, Elkasabany A., Berenson GS.  Brachial Artery Distensibility and Relation to Cardiovascular Risk Factors in Healthy Young Adults (The Bogalusa Heart Study).  Am J Cardiology 2002;89:946-51.  4. Urbina EM, Srinivasan SR, Tang R, Bond MG, Kieltyka L, Berenson GS.  Impact of Multiple Coronary Risk Factors on the Intima-Media Thickness of Different Segments of Carotid Artery in Healthy Young Adults (The Bogalusa Heart Study)  Am J Cardiology 2002;90:952-958.5. Urbina EM, Srinivasan SR, Kieltyka RL, Tang R, Bond MG, Chen W, Berenson GS. Correlates of carotid artery stiffness in young adults:  the Bogalusa Heart Study. Atherosclerosis 2004;176:157-64.6. Urbina EM, Kieltkya L, Tsai J, Srinivasan SR, Berenson GS.  Impact of multiple cardiovascular risk factors on brachial artery distensibility in young adults: The Bogalusa Heart Study.  Am J Hypertens 2005;18:767-771.7. *Urbina EM, Kimball TR, McCoy CE, Khoury PR, Daniels SR, Dolan LM. Youth with Obesity and Obesity related Type 2 Diabetes Demonstrate Abnormalities in Carotid Structure and Function. Circulation. 2009;119:2913-2919. In this article, we demonstrated that not only do youth with type 2 diabetes show more advanced carotid atherosclerosis, but obese youth are already demonstrating adverse arterial stiffness well before the onset of diabetes.  These findings may change the way children are targeted for more aggressive intervention for CV risk factors. I was co-PI on the grant from which these data were collected.  I developed all the vascular testing protocols and supervised training, data collection and performed my own statistical analyses. Science Citation Index indicates this paper has been cited 95 times including:  2012=6, 2013=13, 2014=13, 2015=12, 2016=14, 2017=5.8. *Urbina EM,  Kimball TR, Khoury PR, Daniels SR, Dolan LM.  Increased Arterial Stiffness is Found in Adolescents with Obesity or Obesity-Related Type 2 Diabetes Mellitus.  J Hypertens 2010;28:1692-1698.  This study examined vascular structure and function among lean, ‘healthy’ obese youth and obese youth with type 2 diabetes mellitus.  We found that arterial stiffening can be identified in supposedly ‘healthy’ obese youth well before the onset of type 2 diabetes.  These data will have a major impact on the way we evaluate obesity-related target organ damage and will form the basis for many intervention trials.  As co-PI on the grant from which these data were derived, I developed all the vascular assessment protocols, trained the data collection team and supervised the data entry and statistical support team.  I also independently performed most of the statistical analyses.  Science Citation Index indicates this paper has been cited 90 times including:  2012=7, 2013=14, 2014=11, 201521, 2016=14, 2017=11.9. *Urbina EM, Dolan LM, McCoy CE, Khoury PR, Daniels SR, Kimball TR.  Relationship between elevated arterial stiffness and increased LV mass in adolescents and young adults.  J Peds 2011;158:715-721.  This study demonstrates that increased arterial stiffness is related in a linear fashion to increasing LV mass.  The fact that the increased afterload imposed on the heart by stiffer vessels may lead to adverse cardiac remodeling had been demonstrated in adults but never proven in youth.  These data confirm the need to develop effective therapies for reducing CV risk factor-related arterial stiffness to prevent future CV events.  The abstract associated with this paper was judged in the top 10% of all AHA specialty meeting abstracts and was invited for a special poster symposium at the national AHA meeting.  As co-PI on the grant from which these data were derived, I developed all the vascular assessment protocols, trained the data collection team and supervised the data entry and statistical support team.  I also independently performed the majority of the statistical analyses. Science Citation Index indicates this paper has been cited 28 times including:  2012=4, 2013=4, 2014=4, 2015=4, 2016=7, 2017=4.10. Shah A, Dolan L, Gao Z, Kimball T, Urbina E.  Clustering of Risk Factors:  A Simple Method of Detecting Cardiovascular Disease in Youth.  Pediatrics 2011;127:e312-318.11. *Urbina EM, Khoury PR, McCoy C, Daniels SR, Kimball TR, Dolan LM.  Cardiac and Vascular Consequences of Pre-Hypertension in Youth.  J Clin HTN 2011;13:332-342.  This study stratified adolescents and young adults by BP cutpoints (normo-, pre- and true-hypertensive).  We demonstrated that pre-hypertensive youth are already demonstrating abnormalities in cardiac and vascular structure and function well before progression to sustained, true hypertension.  These data may have an important impact on Pediatric hypertension treatment guidelines.  Cut-points for treatment of adult HTN is based on relating BP levels to hard CV events.  No such longitudinal data is available in pediatrics.  Therefore, treatment is based on arbitrary statistical BP cut-points that may actually be underestimating the degree of target organ damage occurring.  As co-PI on the grant from which these data were derived, I developed all the vascular assessment protocols, trained the data collection team and supervised the data entry and statistical support team.  I also independently performed all of the statistical analyses. Science Citation Index indicates this paper has been cited 80 times including:  2012=4, 2013=11, 2014=7, 2015=22, 2016=24, 2017=9.12. *Urbina EM, Khoury PR, McCoy CE, Dolan LM, Daniels SR, Kimball TR.  Triglyceride to HDL-C Ratio & Increased Arterial Stiffness in Children, Adolescents & Young Adults.  Pediatrics  2013;131:e1082-1090.  TG to HDL ratio correlates with presence of small dense LDL particles, the most atherogenic type of lipoprotein.  We demonstrated for the first time in youth that there was a direct relationship between TG/HDL ratio and arterial stiffness and the effect was strongest in obese youth.  I was PI of this grant and obtained the funding, supervised data collection, analyses and wrote the manuscript.  Science Citation Index indicates this paper has been cited 44 times including:  2013=1, 2014=8, 2015=10, 2016=13, 2017=11.13. Trasande L, Kajunski Fiorino E, Attina T, Berger K, Goldring R, Chemtob C, Levy-Carrick N, Shao Y, Liu M, Urbina E, Reibman J. Associations of World Trade Center exposures with pulmonary and cardiometabolic outcomes among children seeking care for health concerns.  Science Total Environ 2013;444:320-326.14. Urbina EM,  Dabelea D, D’Agostino RB, Jr, Shah, AS, Dolan LM, Hamman RF, Daniels SR, Marcovina S, Wadwa RP.  Effect of Type 1 Diabetes Mellitus on Carotid Structure and Function in Adolescents and Young Adults:  The SEARCH CVD Diabetes Care 2013 Sep; 36(9):2597-2599, PMID:  23564920.15. *Juhola J, Magnussen CG, Berenson GS, Venn A, Burns TL, Sabin MA, Srinivasan SR, Daniels SR,  Davis PH, Chen W, Kähönen M, Taittonen L, Urbina E, Viikari JSA, Dwyer T, Raitakari OT, Juonala M, Combined effects of child and adult elevated blood pressure on subclinical atherosclerosis. The International Childhood Cardiovascular Cohort Consortium.  Circulation 2013:128:217-224. PMID:23780579.  Building on my work collecting carotid ultrasound data in the Bogalusa Heart Study in the 1990s, I participated in this work pooling carotid data from multiple pediatric cohorts.  This work demonstrated the effect that childhood BP has on subclinical atherosclerosis in adulthood.  As co-PI in Bogalusa, I developed the carotid protocols, supervised data collection and participated in analyses of the merged data and manuscript preparation.  Science Citation Index indicates this paper has been cited 57 times including:  2013=1, 2014=8, 2015=9, 2016=22, 2017=15.16. *Michalsky MP, Inge TH, Simmons M, Jenkins TM, Buncher R, Helmrath M, Brandt ML, Harmon CM, Courcoulas A, Chen M, Horlick M, Daniels SR, Urbina EM for the Teen-LABS Consortium.  Cardiovascular Risk Factors in Severely Obese Adolescents: The Teen Longitudinal Assessment of Bariatric Surgery (Teen-LABS) Study.  JAMA Pediatr. 2015 May 1;169(5):438-444. PMID:  25730293.  In this longitudinal study of the safety and efficacy of bariatric surgery in youth, we demonstrated that severely obese youth had significant abnormalities in CV risk factors prior to surgery.  Our ongoing work follows the improvement in these risk factors over time.  As a collaborator on this work, I helped develop the CV risk factor categories, participated in data analyses and manuscript preparation;  Science Citation Index indicates this paper has been cited 12 times including:  2015=3, 2016=2, 2017=7.17. *Shah AS, Wadwa RP, Dabelea D, Hamman RF, D’Agostino Jr, R, Marcovina S, Daniels SR, Dolan LM, Fino NF, Urbina EM.  Arterial Stiffness in Adolescents and Young Adults with and without Type 1 Diabetes: The SEARCH CVD study.  Pediatr Diabetes. 2015 Aug;16(5):367-74.  PMID:  25912292  In this sub-study of the SEARCH for Diabetes multi-center trial, we collected arterial stiffness data on youth with T1D and found increased stiffness as compared to controls.  This was the largest case/control study of arterial stiffness in T1D to date.  As co-PI, I helped write the grant, supervised collection of all arterial stiffness measures and participated in analyses and manuscript preparation.  Science Citation Index indicates this paper has been cited 7 times including:  2015=1, 2016=5, 2017=1.18. *Shah A, Davidson W, Gao Z, Dolan L, Kimball T, Urbina E.  Superiority of Lipoprotein Particle Number to Detect Associations with Arterial Thickness and Stiffness in Obese Youth with and without Pre-diabetes.   JClinLipid 2016:10;610-618.  PMID:  27206949, PMC4876956  In this study we directly measured lipoprotein particle size and number in youth with obesity and pre-diabetes and demonstrated a stronger relationship between these lipid parameters and arterial thickness and stiffness as compared to traditional lipid concentration measures.  I was PI of this grant and obtained the funding, supervised data collection, and participated in analyses and manuscript preparation.  Science Citation Index indicates this paper has been cited 4 times in 2017.19. Koshy TT, Attina TM, Ghassabian A, Gilbert J, Burdine LK, Marmor M, Honda M, Chu DB, Han X, Shao Y, Kannan K, Urbina EM and Trasande L. Serum perfluoroalkyl substances and cardiometabolic consequences in adolescents exposed to the World Trade Center disaster and a matched comparison group. Environ Int. 2017;109:128-135.  PMID 2889021820. Wang L, Filipp S, Urbina E, Gurka M, DeBoer M.  Longitudinal Associations of Metabolic Syndrome Severity between Childhood and Young-Adulthood:  The Bogalusa Heart Study. Metabolic Syndrome and Related Disorders 2018;16:208-214.  PMID: 29584578.PMID: 29584578. 21. Khoury M, Khoury PR, Dolan LM, Kimball TR, Urbina EM.  Clinical Implications of the Revised AAP Pediatric Hypertension Guidelines.  Pediatrics Vol 142, No. 2, August 2018:320180245. : doi: 10.1542/peds.2008-1536

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AMA PRA Category 1 Credits™ (1.00 hours), Non-Physician Attendance (1.00 hours)

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