Methods to evaluate arterial structure and function in children - State-of-the art knowledge

New indices in predicting cardiometabolic risk and its relation to endothelial dysfunction in adolescents: The HELENA study

BACKGROUND AND AIMS

Blood pressure (BP) changes and insulin resistance (IR) are important cardiometabolic risk (CMR) factors; their early identification can contribute to the reduction of cardiovascular events in adulthood. This necessitates the search for more accessible and easily applied indicators for their prediction. Therefore, this study aimed to evaluate the predictive power of the indices, TyG, TG/HDL-c, height-corrected lipid accumulation product (HLAP), and visceral adiposity index (VAI), in identifying the CMR obtained by high BP and IR and to verify their relationship with biomarkers of endothelial dysfunction (ED) in European adolescents.

METHODS AND RESULTS

The anthropometric data and blood biomarkers of 744 adolescents (343 boys and 401 girls) from the Healthy Lifestyle in Europe by Nutrition in Adolescence Cross-Sectional Study (HELENA-CSS), with a mean age of 14.67 (SD 1.15) years, were assessed. The adolescents were then classified according to the presence or absence of high BP and IR. The cut-off points of the indices evaluated for the identification of CMR were determined. The relationship between CMR diagnosed using these indices and ED biomarkers was tested. The HLAP and TG/HDL-c were fair predictors of CMR obtained by IR in male adolescents. These indices showed association with hsCRP in sVCAM-1 in boys, but it lost significance after adjusting for age and body mass index.

CONCLUSION

TG/HDL-c and HLAP indices showed a fair performance in predicting CMR, obtained by IR, in male adolescents. ED showed no association with the CMR identified by the indices.

The effect of perinatal HIV and antiretroviral therapy on vascular structure and function in young people: A systematic review and meta-analysis

BACKGROUND AND AIMS

Perinatal HIV infection (PHIV) and prolonged use of antiretroviral therapy (ART) may increase the likelihood of developing subclinical vascular dysfunction at an early age. We conducted a systematic review to assess the effect of PHIV and ART on intima-media thickness (IMT), arterial stiffness and endothelial function in individuals aged 6-25 years.

METHODS

Medline, Embase and Web of Science were searched, and studies screened by two independent reviewers. We performed a meta-analysis on selected studies reporting on IMT.

RESULTS

A total of 680 studies were retrieved from the databases, with 21 studies deemed eligible for qualitative analysis. There were few studies assessing IMT, arterial stiffness and endothelial function. More than half of the studies found either increased IMT, stiffer arteries or impaired endothelial function in PHIV compared to uninfected controls. A minority of the studies reported that the two groups had similar vascular parameters, a conflicting finding. There was a lack of standardisation for IMT assessment and reporting in numerous studies. In a meta-analysis of seven studies with matching methodologies, IMT was higher in PHIV compared to uninfected controls, (mean difference, 0.05 (0.01-0.09; p = 0.01) but heterogeneity between the studies was substantial (I², 96.7%; p < 0.001).

CONCLUSIONS

PHIV may affect vascular structure and function. Existing studies are generally small, often contradictory, and predominantly cross-sectional in design. Further studies are required to understand vascular health in PHIV to identify cardiovascular disease risk and improve interventional strategies aimed at prevention and treatment of early vascular changes in this population.

Endothelial Dysfunction in Childhood Cancer Survivors: A Narrative Review

Assessment of endothelial dysfunction in cancer survivors may have a role in the early identification of non-communicable diseases and cardiovascular late effects. Oncological therapies may impair endothelial function. Therefore, in patients such as childhood cancer survivors who could benefit from early cardioprotective pharmacological interventions, it is essential to monitor endothelial function, even if the optimal methodology for investigating the multifaceted aspects of endothelial dysfunction is still under debate. Biochemical markers, as well as invasive and non-invasive tools with and without pharmacological stimuli have been studied. Human clinical studies that have examined lifestyle or cancer treatment protocols have yielded evidence showing the involvement of lipid and lipoprotein levels, glycemic control, blood pressure, adiposity, inflammation, and oxidative stress markers on the state of endothelial health and its role as an early indicator of cardiometabolic risk. However, with regards to pharmacological interventions, cautious interpretation of the result attained whilst monitoring the endothelial function is warranted due to methodological limitations and substantial heterogeneity of the results reported in the published studies. In this narrative review, an overview of evidence from human clinical trials examining the effects of cancer therapies on endothelial disease is provided together with a discussion of endothelial function assessment using the different non-invasive techniques available for researchers and clinicians, in recent years.

Arterial stiffness in children with primary hypertension is related to subclinical inflammation

Introduction

The immune system can trigger an inflammatory process leading to blood pressure elevation and arterial damage. The aim of the study was to assess the relation between subclinical inflammation and arterial damage in pediatric patients with primary hypertension (PH) and to establish the usefulness of neutrophil-to-lymphocyte (NLR) and platelet-to-lymphocyte (PLR) ratios, and mean platelet volume (MPV) as markers of arterial damage in these subjects.

Material and methods

In 119 children with PH (14.94 ±2.76 years) and 45 healthy children (14.91 ±2.69 years) we analyzed markers of subclinical inflammation (NLR, PLR, MPV), clinical and biochemical parameters, office blood pressure, ambulatory blood pressure monitoring (ABPM), central blood pressure, aortic pulse wave velocity (aPWV), augmentation index corrected for heart rates 75 (AIx75HR), carotid intima media thickness (cIMT), and common carotid artery stiffness (E-tracking).

Results

Children with PH were characterized by significantly higher neutrophil (3.9 ±1.7 vs. 3.0 ±1.0 [1000/µl], p < 0.001) and platelet counts (271.9 ±62.3 vs. 250.3 ±60.3 [1000/µl], p = 0.047), NLR (1.9 ±1.5 vs. 1.3 ±0.4, p = 0.010), PLR (131.4 ±41.9 vs. 114.7 ±37.6, p = 0.020), aPWV (5.36 ±0.88 vs. 4.88 ±0.92 m/s, p = 0.004), and cIMT (0.46 ±0.07 vs. 0.43 ±0.07 mm, p = 0.002) compared to healthy children. In PH children NLR correlated positively (p < 0.05) with: systolic, diastolic and mean blood pressure in ABPM (r = 0.243, r = 0.216, r = 0.251), aPWV [m/s] (r = 0.241), aPWV Z-score (r = 0.204), and common carotid artery PWVbeta [m/s] (r = 0.202).

Conclusions

There is a link between arterial stiffness and subclinical inflammation in pediatric patients with primary hypertension. Neutrophil-to-lymphocyte ratio may serve as a promising marker of arterial stiffness in pediatric patients affected by primary hypertension.

Risk Assessment and Clinical Management of Children and Adolescents with Heterozygous Familial Hypercholesterolaemia. A Position Paper of the Associations of Preventive Pediatrics of Serbia, Mighty Medic and International Lipid Expert Panel

Heterozygous familial hypercholesterolaemia (FH) is among the most common genetic metabolic lipid disorders characterised by elevated low-density lipoprotein cholesterol (LDL-C) levels from birth and a significantly higher risk of developing premature atherosclerotic cardiovascular disease. The majority of the current pediatric guidelines for clinical management of children and adolescents with FH does not consider the impact of genetic variations as well as characteristics of vascular phenotype as assessed by recently developed non-invasive imaging techniques. We propose a combined integrated approach of cardiovascular (CV) risk assessment and clinical management of children with FH incorporating current risk assessment profile (LDL-C levels, traditional CV risk factors and familial history) with genetic and non-invasive vascular phenotyping. Based on the existing data on vascular phenotype status, this panel recommends that all children with FH and cIMT ≥0.5 mm should receive lipid lowering therapy irrespective of the presence of CV risk factors, family history and/or LDL-C levels Those children with FH and cIMT ≥0.4 mm should be carefully monitored to initiate lipid lowering management in the most suitable time. Likewise, all genetically confirmed children with FH and LDL-C levels ≥4.1 mmol/L (160 mg/dL), should be treated with lifestyle changes and LLT irrespective of the cIMT, presence of additional RF or family history of CHD.

Effects of L-Citrulline Supplementation and Aerobic Training on Vascular Function in Individuals with Obesity across the Lifespan

Children with obesity are at higher risk for developing cardiometabolic diseases that once were considered health conditions of adults. Obesity is commonly associated with cardiometabolic risk factors such as dyslipidemia, hyperglycemia, hyperinsulinemia and hypertension that contribute to the development of endothelial dysfunction. Endothelial dysfunction, characterized by reduced nitric oxide (NO) production, precedes vascular abnormalities including atherosclerosis and arterial stiffness. Thus, early detection and treatment of cardiometabolic risk factors are necessary to prevent deleterious vascular consequences of obesity at an early age. Non-pharmacological interventions including L-Citrulline (L-Cit) supplementation and aerobic training stimulate endothelial NO mediated vasodilation, leading to improvements in organ perfusion, blood pressure, arterial stiffness, atherosclerosis and metabolic health (glucose control and lipid profile). Few studies suggest that the combination of L-Cit supplementation and exercise training can be an effective strategy to counteract the adverse effects of obesity on vascular function in older adults. Therefore, this review examined the efficacy of L-Cit supplementation and aerobic training interventions on vascular and metabolic parameters in obese individuals.

The Effect of Long-Term Atorvastatin Therapy on Carotid Intima-Media Thickness of Children With Dyslipidemia

Carotid intima-media thickness (cIMT) has been proposed as an early marker of subclinical atherosclerosis in high risk children. Children with heterozygous familial hypercholesterolemia have greater cIMT than matched healthy controls or their unaffected siblings. Statin therapy may delay the progression of cIMT, although long-term studies in children are scarce. We evaluated the effect of atorvastatin treatment on cIMT in children with dyslipidemia. We studied 81 children/adolescents, 27 with severe dyslipidemia (low-density lipoprotein cholesterol [LDL-C] ≥190 mg/dL) and 54 sex- and age-matched healthy controls; LDL-C ≤ 130 mg/dL and lipoprotein (a), Lp(a), ≤30 mg/dL. In the children with dyslipidemia, cIMT was measured twice, before and on treatment (18.2 ± 7.7 months). Anthropometric data, a full lipid profile, liver, kidney, and thyroid function were evaluated. Males with dyslipidemia had a greater cIMT than male controls after adjustment for other factors (P = .049). In addition, a nonstatistically significant decrease in cIMT was observed after treatment (P = .261). Treatment with atorvastatin resulted in a significantly improved lipid profile. Females with dyslipidemia had a significantly thinner cIMT than males. Children with normal and high Lp(a) levels had similar cIMT values. In conclusion, treatment with atorvastatin had a beneficial effect on the lipid profile and cIMT progression in children with severe dyslipidemia.

Hypophosphatasia in adolescents and adults: overview of diagnosis and treatment

This article provides an overview of the current knowledge on hypophosphatasia-a rare genetic disease of very variable presentation and severity-with a special focus on adolescents and adults. It summarizes the available information on the many known mutations of tissue-nonspecific alkaline phosphatase (TNSALP), the epidemiology and clinical presentation of the disease in adolescents and adults, and the essential diagnostic clues. The last section reviews the therapeutic approaches, including recent reports on enzyme replacement therapy (EnzRT).

Assessment of intima-media thickness of the carotid artery and intraluminal diameter of the brachial artery as cardiovascular risk markers in Brazilian adolescents with overweight or obesity

Background The intima-media thickness of the carotid artery (cIMT) and endothelial dysfunction are associated with cardiovascular (CV) disease. Objectives To evaluate the correlation between cIMT, brachial intraluminal diameter and flow-mediated vasodilation on the reactive hyperemia phase in adolescents with obesity with predictors of CV risk. Methods Seventy-three pubertal patients with overweight or obesity were evaluated (45 girls) with a mean (standard deviation [SD]) age of 12.9 (2.5) years. Patients underwent anthropometric measurements and had the lipid profile, oral glucose tolerance test (oGTT) and serum intercellular adhesion molecule-1 (sICAM-1) levels analyzed. The ratios of the waist circumference (WC)/height (WHtR) and triglycerides (TG)/high-density lipoprotein cholesterol (HDL-C), homeostatic model assessment of insulin resistance (HOMA-IR), the Matsuda index and insulin area under the curve (AUC) were calculated. All patients were evaluated for cIMT and arterial blood flow velocity of the brachial artery. Results 75.3% of the patients had high cIMT values. We found a positive correlation between WHtR and cIMT (r = 0.233; p = 0.050). There was a positive correlation between sICAM-1 and insulin AUC (r = 0.323; p = 0.012) and WHtR (r = 0.258; p = 0.047). Patients with abnormal arterial dilation had higher sICAM-1 values (p = 0.02) despite having smaller WHtR (p = 0.046). Conclusions These adolescents with obesity had high cIMT values. Insulin resistance was associated with sICAM-1. Endothelial dysfunction was positively correlated with sICAM-1. There is no consensus about what the best laboratorial approach to evaluate insulin resistance in adolescents is, and the cutoff values of each method are arbitrary. So, as we saw earlier, the association between anthropometric data (WHtR) and ultrasound findings could be useful to evaluate the CV risk of these adolescents with obesity, because of its practical, direct and low-cost value.

Arterial stiffness in children and adolescents with masked and sustained hypertension

This study recruited 85 healthy children and adolescents, aged 6-18 years, from a school-based blood pressure (BP) screening study and performed office BP measurements, 24-h ambulatory blood pressure monitoring (24-h ABPM) and 24-h pulse wave analysis. Prevalence of BP phenotypes was assessed, factors that may predict hypertension (HTN) in ABPM were examined and the effect of BP phenotypes, as well as school, office, and ambulatory BP parameters on pulse wave velocity (PWV), was investigated. Forty-five (54.9%) of the children were normotensives, 8 (9.7%) were white coat hypertensives (WCH), 19 (23.2%) had masked hypertension (MH), and 10 (12.2%) had sustained HTN. Estimated adjusted marginal means for 24-h PWV were 4.79 m/s (95% CI 4.65-4.94) for sustained hypertensives, 4.72 m/s (95% CI 4.62-4.82) for MH, 4.38 m/s (95% CI 4.23-4.54) for WCH, and 4.33 m/s (95% CI 4.26-4.40) for normotensives (sustained hypertensives versus normotensives and WCH, p < 0.001, MH versus normotensives and WCH, p < 0.005). Neither body mass index (BMI) z-score nor school systolic BP (SBP) z-score could predict HTN by ABPM. Office SBP z-score was associated with 1.74 times increased odds ratio to have HTN in ABPM. Sustained HTN and MH were independent predictors of 24-h PWV after adjustment for age, sex, and BMI z-score. In conclusion, arterial stiffness in children and adolescents was assessed by 24-h PWV associates with mean ambulatory BP. Both school and office BP measurements could not predict HTN in ABPM or increasing PWV. HTN in ABPM was independently associated with the risk of higher PWV compared with normotensive and WCH phenotype.

Predictors and Consequences of Pediatric Hypertension: Have Advanced Echocardiography and Vascular Testing Arrived?

PURPOSE OF REVIEW

Pediatric hypertension is relatively common and associated with future adult hypertension. Elevated blood pressure in youth predicts future adult cardiovascular disease and blood pressure control can prevent progression of pediatric kidney disease. However, pediatric blood pressure is highly variable within a given child and among children in a population.

RECENT FINDINGS

Therefore, modalities to index aggregate and cumulative blood pressure status are of potential benefit in identifying youth in danger of progression from a risk factor of subclinical phenotypic alteration to clinically apparent event. In this review, we advocate for the health risk stratification roles of echocardiographically assessed cardiac remodeling, arterial stiffness assessment, and assessment by ultrasound of arterial thickening in children and adolescents with hypertension.

Reference Intervals of Central Aortic Blood Pressure and Augmentation Index Assessed with an Oscillometric Device in Healthy Children, Adolescents, and Young Adults from Argentina

Age-related reference intervals (RIs) of central (aortic) systolic blood pressure (cSBP) and augmentation index (cAIx) obtained from large healthy population are lacking in Argentina (South America). Aims. To analyze the existence of associations among cSBP and cAIx with demographic, anthropometric, and hemodynamic parameters and to generate percentile curves and RIs adjusted to each level of age and gender and/or body height. cSBP and cAIx were measured in 1038 healthy children, adolescents, and young adults. First, we evaluated if RIs for males and females were necessary using correlation and covariate analysis. Second, mean (M) and standard deviation (SD) age-related equations were obtained for cSBP and cAIx, using parametric regression methods based on fractional polynomials. Third, age specific percentiles curves were generated. Fourth, body height specific percentiles curves were generated using a similar procedure. The obtained equations (considering age as independent variable) for all subjects (cSBP^0.26 and (cAIx + 12.001)^0.5) were as follows: cSBP Mean = 3.0581 + 0.2189 log(Age) − 0.001044Age; cSBP SD = −0.03919 + 0.1535 log(Age) − 0.004564Age; cAIx mean = 9.5226 − 6.1599 log(Age) + 0.1450Age; cAIx SD = 1.3880 − 0.8468 log(Age) + 0.03212Age. This study, performed in Argentinean healthy children, adolescents, and young adults with ages of 5 to 22 years, provides the first RIs and percentile curves of cSBP and cAIx. Additionally, specific body height-related cAIx percentiles are reported for the analyzed population. The RIs and percentiles contribute to the knowledge of arterial dynamic evolution along the normal aging process and the interpretation of data obtained in clinical research and daily clinical practice.

The importance of cardiovascular disease in pediatric transplantation and its link to the kidneys

Cardiovascular disease is a frequent cause of morbidity and mortality in pediatric patients following solid organ transplant. CKD is also common in pediatric patients after a solid organ transplant, and the link between CKD and cardiovascular morbidity is strong. In this review, we examine potential etiologies to explain the risk of cardiovascular morbidity and mortality in pediatric solid organ recipients and identify targets for improving outcomes.

Reference intervals and percentiles for carotid-femoral pulse wave velocity in a healthy population aged between 9 and 87 years

There is little information regarding age-related reference intervals (RIs) of carotid-femoral pulse wave velocity (cfPWV) for large healthy populations in South America. The aims of this study were to determine cfPWV RIs and percentiles in a cohort of healthy children, adolescents, and adults and to generate year-to-year percentile curves and body-height percentile curves for children and adolescents. cfPWV was measured in 1722 healthy participants with no cardiovascular risk factors (9-87 years, 60% men). First, RIs were evaluated for males and females through correlation and covariate analysis. Then, mean and standard deviation age-related equations were obtained for cfPWV using parametric regression methods based on fractional polynomials and age-specific (year-to-year) percentile curves that were defined using the standard normal distribution. Age-specific first, 2.5th, 5th, 10th, 25th, 50th, 75th, 90th, 95th, 97.5th, and 99th percentile curves were calculated. Finally, height-related cfPWV percentile curves for children and adolescents (<21 years) were established. After adjusting for age and blood pressure differences with respect to females, males showed higher cfPWV levels (6.60 vs 6.45 m/s; P < .01). Thus, specific RIs for males and females were reported. The study provides the largest database to date concerning cfPWV in healthy people from Argentina. Specific RIs and percentiles of cfPWV are now available according to age and sex. Specific percentiles of cfPWV according to body height were reported for people younger than 21 years.