Report of the National Heart, Lung, and Blood Institute's Working Group on obesity and other cardiovascular risk factors in congenital heart disease

Understanding the barriers and facilitators that impact physical activity levels in children and adolescents with Congenital Heart Disease (CHD): a rapid review

BACKGROUND

Physical activity is vital for improving health in patients with congenital heart disease (CHD), yet physical activity rates in this group are significantly lower than those in the general population. The reasons for these low rates among patients with CHD have not been thoroughly documented. This review aimed to identify barriers and facilitators of physical activity in children and adolescents with CHD.

METHODS

A rapid review was performed across five databases: PubMed, Scopus, CINAHL, PsycINFO, and PEDRO, focusing on studies related to physical activity in children or adolescents with CHD. Barriers and facilitators were categorized using the COM-B model and classified as non-modifiable or as individual, sociocultural, socioeconomic, or environmental modifiable factors. Descriptive analysis and concept maps were used to describe physical activity barriers and facilitators further.

RESULTS

Forty-nine studies were included. Most articles were quantitative (76%) and assessed non-modifiable demographic influences like age and gender. Self-efficacy was cited as the most common individual modifiable facilitator of physical activity. Self-imposed limitations and self-perceived barriers such as fears and anxiety, feelings of inadequacy, and lack of enjoyment were barriers to physical activity. Sociocultural influences included support from parents, teachers, and peers, though they sometimes hindered activity due to their anxiety and lack of knowledge. Socioeconomic and environmental barriers included costs and inadequate resources for physical activity.

CONCLUSION

This review identified barriers and facilitators to physical activity, highlighting non-modifiable factors like gender and age, as well as modifiable factors such as anxiety, self-efficacy, and parental involvement. Environmental factors at home and school also play a role. This review's findings were organized using the COM-B model, categorizing barriers and facilitators into capability, opportunity, and motivation, providing a deeper understanding of what must be considered when developing interventions for this population. Future research should explore the views of clinicians, patients, and families on the factors identified here and conduct longitudinal studies to track influences on physical activity over time.

TRIAL REGISTRATION

PROSPERO: CRD42024516250.

Coronary anomalies in single ventricles: Insights from selective angiographic assessment

BACKGROUND

Adults with congenital heart disease have a higher risk of coronary artery disease compared to the general population. However, there is limited information on coronary artery distribution in patients with a single ventricle (SV), which is important in understanding potential cardiovascular events. This study aimed to evaluate coronary artery morphology and anomalies in patients with SV based on selective coronary angiography (CAG).

METHODS

We performed a retrospective single-center study including 80 patients with SV [median age, 29 years (range 13-50); 54 % males] who underwent selective CAG at our institution between 2019 and 2023. Patients were classified into either single right or left ventricular (SRV and SLV) morphologies and categorized into D-, L-, and X-loops based on the rules of cardiovascular looping. Coronary artery morphology, dominance, and the abnormality of origin were evaluated.

RESULTS

Of the 80 SV patients, 56 had SRV and 24 had SLV. Patients with coronary artery looping surrounding the rudimentary chamber were more frequent in cases with D-loops. In patients with SV, right coronary artery dominance was observed in 70 %, and anomalous origins of coronary artery origins were found in 36.3 % of cases, with a higher frequency of L-loops. Overall, cardiovascular events were observed in patients with SV as follows: 46 % of patients had arrhythmias, 13 % had heart failure, and 8 % had thrombosis; there were no cardiovascular deaths. A single coronary artery was identified in 9 cases (11 %) of SV patients, exclusively in SRV, of which 2 cases (22 %) had arrhythmias and 1 case (11 %) had thrombus.

CONCLUSION

Selective CAG revealed a high prevalence of coronary artery anomalies in patients with SV, emphasizing the importance of comprehensive assessment and long-term follow-up to manage cardiovascular risk in this patient population.

Height and weight trajectories are associated with submaximal and maximal exercise capacity in children with congenital heart defects

Children with congenital heart defects (CHD) are often short/lightweight relative to peers. Limited growth, particularly height, may reflect energy deficits impacting physical activity. Latent class analyses of growth from birth and Bruce treadmill exercise data retrospectively identified for height, weight, and body mass index z-scores growth trajectories. Linear regression models examined exercise parameters by growth trajectory, adjusting for age/sex/CHD severity. A total of 213 children with CHD (39% female, 12.1 ± 2.9 years) achieved 85.8 ± 10.1% of the predicted peak heart rate. Peak heart rate among children whose height was consistently below average (class 1) was 15.2 ± 4.9 beats/min lower than children with other height trajectories. These children also attained a lower percentage of predicted peak heart rate. Children whose weight (p = 0.03) or body mass index (p < 0.001) z-score increased throughout childhood had significantly lower exercise duration (mean difference 1-2 min) than children whose growth trajectories were stable or declined. Children with above-average weight or an increasing body mass index also used a higher percentage of their heart rate reserve at each submaximal exercise stage. A very low height z-score trajectory is associated with decreased exercise capacity that may increase the risk for morbidities associated with a sedentary lifestyle. Future studies should examine potential mechanisms for the observed height deficits, such as an inadequate energy supply that could impact physical activity participation, congestive heart failure, cyanosis, pubertal stage, supplemental feeding history, or familial growth patterns. Prospective studies examining growth in relation to objective measures of daily physical activity are required.

The prevalence of obesity in children with CHD: what has changed over the past decade in Southwestern Ontario?

OBJECTIVE

To assess the prevalence of obesity and investigate any changes in body mass index in children with CHD compared to age-matched healthy controls, in Southwestern Ontario.

METHODS

The body mass index z-scores of 1259 children (aged 2-18) with CHD were compared with 2037 healthy controls. The body mass index z-scores of children who presented to our paediatric cardiology outpatient clinic from 2018 to 2021 were compared with previously collected data from 2008 to 2010. A longitudinal analysis of patients with data in both cohorts was also completed.

RESULTS

In total, 21.4% of patients with CHD and 26.6% of healthy controls were found to be overweight or obese (p < 0.001). The 2018-2021 cohort of CHD patients and controls had significantly higher body mass index z-scores compared to the 2008-2010 cohort (p < 0.001). Longitudinal analysis showed that body mass index z-scores significantly increased over time for CHD patients with data in both cohorts (2018-2021: M = 0.59, SD = 1.26; 2008-2010: M = -0.04, SD = 1.05; p < 0.001).

CONCLUSION

The prevalence of obesity in all children, irrespective of CHD, is rising. The coexistence of obesity and CHD may pose additional cardiovascular risks and complications.

Atherosclerotic Risk Factor Prevalence in Adults With Congenital Heart Disease: A Meta-Analysis

Background

The risk of atherosclerotic cardiovascular disease (ASCVD) in adults with congenital heart disease (ACHD) is comparable to that of the general population and is driven by traditional ASCVD risk factors.

Objectives

The aim of the study was to estimate the prevalence of traditional ASCVD risk factors (hypertension, dyslipidemia, diabetes mellitus [DM], obesity, smoking, and physical inactivity) in ACHD and compare it with the general population.

Methods

A systematic literature search was conducted up to May 15, 2024, to identify studies (with or without control group) reporting the prevalence of ASCVD risk factors in ACHD. Meta-analyses were conducted to synthesize the prevalence of risk factors and compare it with that of the general population, where applicable.

Results

We identified 62 studies (30 controlled) encompassing 110,469 ACHD (mean age 39 years; 52% males, 88% with simple/moderate congenital heart disease complexity). Of these, 54% (45%-63%) reported lack of regular exercise, 33% (26%-40%) had hypertension, 18% (14%-22%) were obese, 17% (11%-25%) had dyslipidemia, 12% (9%-14%) were current smokers, and 7% (5%-9%) had DM. The prevalence of ASCVD risk factors was similar in ACHD and controls, with the exception of DM (higher prevalence in ACHD) and smoking (lower prevalence in ACHD). Significant heterogeneity was observed among the included studies, partially explained by differences in age, congenital heart disease complexity, and the presence of cyanosis.

Conclusions

Except for DM and smoking, the prevalence of traditional ASCVD risk factors is similar in ACHD compared to the general population. Further research is needed to determine whether interventions applied in the general population are also effective in ACHD.

Living with Congenital Aortic Stenosis: Exercise Restriction, Patterns of Adherence, and Quality of Life

Modern consensus panel guidelines recommend restriction from most organized sports for patients with moderate or severe aortic stenosis (AS). However, there is little published data on how frequently physicians deviate from guidelines, how well patients adhere to exercise restrictions, or the effect of restriction on patient-reported quality of life. In this study, we surveyed 93 subjects with AS and their cardiologists regarding participation in organized sports, physical activity, weightlifting, and exercise restriction. Subjects completed the pediatric quality of life inventory (PedsQL) and the pediatric cardiac quality of life inventory (PCQLI). We found that subjects with severe AS (n = 3) were commonly, but not universally, restricted from organized sports (n = 2, 66%). Subjects with moderate AS (n = 40) were rarely restricted from organized sports (n = 6, 17%). No physician-specific characteristics were associated with increased likelihood of recommending exercise restriction. Subjects were more likely to be restricted if they were older (16 years vs. 13 years, p 0.02) and had moderate versus mild AS (p 0.013). PCQLI scores for teens and young adults with AS (age 13-25) were lower than a comparison group of patients with mild congenital heart disease. For all age groups, the PedsQL social functioning score was lower for subjects with exercise restriction (p 0.052). In summary, cardiologists apply consensus guidelines leniently when restricting patients with moderate/severe AS from organized sports and weightlifting. Patients with AS routinely adhere to exercise restriction recommendations. Children and young adults with AS and exercise restriction have lower QOL scores in the social functioning domain.

Participation in Competitive Sports by Patients With Congenital Heart Disease: AHA/ACC and EAPC/ESC/AEPC Guidelines Comparison

Sports participation in patients with congenital heart disease is an evolving subject. The American Heart Association/American College of Cardiology released a set of guidelines that advise the type and level of sports participation based primarily on anatomical defects with secondary consideration given to hemodynamic effects. Recently, the European Association of Preventive Cardiology/European Society of Cardiology/Association for European Paediatric and Congenital Cardiology offered a contrasting approach to sports participation that is based on hemodynamic and electrophysiological profiles of each patient, regardless of anatomical consideration. These guidelines are drastically different in their approaches but do have some similarities. In this review, we compare both documents, focusing on the aim, population, classification of sports, and the methodology of making recommendations. This review aims to assist practicing cardiologists in integrating the available published data and recommendations when counseling patients for sports participation.

Flexible wearable intelligent sensing system for wheelchair sports monitoring

The application of wearable intelligent systems toward human-computer interaction has received widespread attention. It is still desirable to conveniently promote health and monitor sports skills for disabled people. Here, a wireless intelligent sensing system (WISS) has been developed, which includes two ports of wearable flexible triboelectric nanogenerator (WF-TENG) sensing and an upper computer digital signal receiving intelligent processing. The WF-TENG sensing port is connected by the WF-TENG sensor and flexible printed circuit (FPC). Due to its flexibility, the WF-TENG sensing port can be freely adhered on the surface of human skin. The WISS can be applied to entertainment reaction training based on human-computer interaction, and to the technical judgment and analysis on wheelchair curling sport. This work provides new application opportunities for wearable devices in the fields of sports skills monitoring, sports assistive devices and health promotion for disabled people.

A 12-week lifestyle intervention: effects on fatigue, fear, and nutritional status in children with a Fontan circulation

Introduction

Children and adolescents with a Fontan circulation are less physically active compared to healthy peers. In the current study, effects of a 12-week lifestyle intervention on fatigue, fears regarding exercise, caloric intake, rest energy expenditure (REE), and body composition were measured in children with a Fontan circulation.

Methods

This study was a semi-cross-over randomized controlled trial. The lifestyle intervention consisted of a 12-week high-weight resistance training (three supervised training sessions a week) supported by high-protein diet (>2 g/kg) and tailored recommended caloric intake. Fatigue (measured by the validated PedsQol Multidimensional Fatigue Scale), fears regarding exercise (measured on a fear thermometer), REE (measured using indirect calorimetry), caloric intake and body composition using air displacement plethysmography, and four-skinfold method were measured before and after the intervention and control period.

Results

Twenty-seven pediatric Fontan patients, median age 12.9 years (IQR: 10.5-16.2), of the included 28 patients successfully completed the program. Before training, both child- and parent-reported levels of fatigue were significantly worse on all domains (general, sleep/rest, and cognitive fatigue) compared to healthy peers. After training, parent-reported fatigue significantly improved on the general and cognitive fatigue domains [effect size +16 points (7-25), p < 0.001, and +10 points (2-17), p = 0.015, compared to the control period]. Before training, fear regarding exercise scored on the fear thermometer was low for both children and parents (median score 1 and 2, respectively, on a scale of 0-8). After training, child-reported fear decreased further compared to the control period [effect size -1.4 points (-2.3 to -0.6), p = 0.001]. At baseline, children had increased REE +12% compared to reference values, which did not change after exercise. Children ate an average of 637 calories below recommended intake based on REE, caloric deficit became smaller after the intervention, and protein intake increased compared to the control period [-388 calories (-674 to -102), p = 0.008, and +15 g (0.4-30), p = 0.044]. Body fat percentage did not change significantly.

Conclusion

A 12-week lifestyle intervention improved parent-reported fatigue symptoms in the children, further decreased child-reported fears, and increased caloric and protein intake.

Decreased lipid levels in adult with congenital heart disease: a systematic review and Meta-analysis

BACKGROUND

Metabolic disorders were a health problem for many adults with congenital heart disease, however, the differences in metabolic syndrome-related metabolite levels in adults with congenital heart disease compared to the healthy population were unknown.

METHODS

We collected 18 studies reporting metabolic syndrome-associated metabolite levels in patients with congenital heart disease. Data from different studies were combined under a random-effects model using Cohen's d values.

RESULTS

The results found that the levels of total cholesterol (Cohen's d -0.68, 95% CI: -0.91 to -0.45), high-density lipoprotein cholesterol (Cohen's d -0.63, 95% CI: -0.89 to -0.37), and low-density lipoprotein cholesterol (Cohen's d -0.32, 95% CI: -0.54 to -0.10) were significantly lower in congenital heart disease patients compared with controls. Congenital heart disease patients also had a lower body mass index (Cohen's d -0.27, 95% CI: -0.42 to -0.12) compared with controls. On the contrary, congenital heart disease patients had higher levels of hemoglobin A1c (Cohen's d 0.93, 95% CI: 0.17 to 1.70) than controls. Meanwhile, there were no significant differences in triglyceride (Cohen's d 0.07, 95% CI: -0.09 to 0.23), blood glucose (Cohen's d -0.12, 95% CI: -0.94 to 0.70) levels, systolic (Cohen's d 0.07, 95% CI: -0.30 to 0.45) and diastolic blood pressure (Cohen's d -0.10, 95% CI: -0.39 to 0.19) between congenital heart disease patients and controls.

CONCLUSIONS

The lipid levels in patients with congenital heart disease were significantly lower than those in the control group. These data will help in the health management of patients with congenital heart disease and guide clinicians.

PROSPERO REGISTRATION NUMBER

CRD42022228156.

Personalized Flexible Meal Planning for Individuals With Diet-Related Health Concerns: System Design and Feasibility Validation Study

BACKGROUND

Chronic diseases such as heart disease, stroke, diabetes, and hypertension are major global health challenges. Healthy eating can help people with chronic diseases manage their condition and prevent complications. However, making healthy meal plans is not easy, as it requires the consideration of various factors such as health concerns, nutritional requirements, tastes, economic status, and time limits. Therefore, there is a need for effective, affordable, and personalized meal planning that can assist people in choosing food that suits their individual needs and preferences.

OBJECTIVE

This study aimed to design an artificial intelligence (AI)-powered meal planner that can generate personalized healthy meal plans based on the user's specific health conditions, personal preferences, and status.

METHODS

We proposed a system that integrates semantic reasoning, fuzzy logic, heuristic search, and multicriteria analysis to produce flexible, optimized meal plans based on the user's health concerns, nutrition needs, as well as food restrictions or constraints, along with other personal preferences. Specifically, we constructed an ontology-based knowledge base to model knowledge about food and nutrition. We defined semantic rules to represent dietary guidelines for different health concerns and built a fuzzy membership of food nutrition based on the experience of experts to handle vague and uncertain nutritional data. We applied a semantic rule-based filtering mechanism to filter out food that violate mandatory health guidelines and constraints, such as allergies and religion. We designed a novel, heuristic search method that identifies the best meals among several candidates and evaluates them based on their fuzzy nutritional score. To select nutritious meals that also satisfy the user's other preferences, we proposed a multicriteria decision-making approach.

RESULTS

We implemented a mobile app prototype system and evaluated its effectiveness through a use case study and user study. The results showed that the system generated healthy and personalized meal plans that considered the user's health concerns, optimized nutrition values, respected dietary restrictions and constraints, and met the user's preferences. The users were generally satisfied with the system and its features.

CONCLUSIONS

We designed an AI-powered meal planner that helps people create healthy and personalized meal plans based on their health conditions, preferences, and status. Our system uses multiple techniques to create optimized meal plans that consider multiple factors that affect food choice. Our evaluation tests confirmed the usability and feasibility of the proposed system. However, some limitations such as the lack of dynamic and real-time updates should be addressed in future studies. This study contributes to the development of AI-powered personalized meal planning systems that can support people's health and nutrition goals.

Obesity in Pediatric Congenital Heart Disease: The Role of Age, Complexity, and Sociodemographics

The prevalence of obesity in children with congenital heart disease (CHD) is greater than 25%, putting these patients at-risk for increased surgical morbidity and mortality. Our goal was to determine the association between CHD complexity, sociodemographic factors, and obesity. Our hypothesis was that among CHD patients, the odds of obesity would be highest in older children with simple CHD, and in all children with a lower socioeconomic status. We conducted a retrospective cohort study, reviewing electronic medical records of children aged 2-17 years from over 50 outpatient pediatric clinics in Houston, TX. Children were classified as simple or moderate/complex CHD, and obesity was defined by BMI ≥ 95th percentile for age and sex. Logistic regression was used to determine the association between sociodemographic factors and CHD complexity with obesity. We identified 648 CHD and 369,776 non-CHD patients. Children with simple CHD had a similar odds of obesity as non-CHD children. Children with CHD had a higher prevalence of obesity if they were older, male, Black, Hispanic, and publicly insured. Children with moderate/complex CHD had lower odds of obesity [OR 0.24 (95% CI 0.07-0.73)], however their predicted probability of obesity approached that of the general population as they aged. Additionally, there was an incremental relationship with poverty and obesity [1.01 (1.01-1.01)]. Awareness of which patients with CHD are at highest risk of obesity may help in targeting interventions to assist at-risk patients maintain a healthy lifestyle.

Prescription medication use after congenital heart surgery

BACKGROUND

Improvements in mortality after congenital heart surgery have necessitated a shift in focus to postoperative morbidity as an outcome measure. We examined late morbidity after congenital heart surgery based on prescription medication use.

METHODS

Between 1953 and 2009, 10,635 patients underwent congenital heart surgery at <15 years of age in Finland. We obtained 4 age-, sex-, birth-time, and hospital district-matched controls per patient. The Social Insurance Institution of Finland provided data on all prescription medications obtained between 1999 and 2012 by patients and controls. Patients were assigned one diagnosis based on a hierarchical list of cardiac defects and dichotomised into simple and severe groups. Medications were divided into short- and long-term based on indication. Follow-up started at the first operation and ended at death, emigration, or 31 December, 2012.

RESULTS

Totally, 8623 patients met inclusion criteria. Follow-up was 99.9%. In total, 8126 (94%) patients required prescription medications. Systemic anti-bacterials were the most common short-term prescriptions among patients (93%) and controls (88%). Patients required betablockers (simple hazard ratio 1.9, 95% confidence interval 1.7-2.1; severe hazard ratio 6.5, 95% confidence interval 5.3-8.1) and diuretics (simple hazard ratio 3.2, 95% CI 2.8-3.7; severe hazard ratio 38.8, 95% CI 27.5-54.7) more often than the general population. Both simple and severe defects required medication for cardiovascular, gastrointestinal, psychiatric, neurologic, metabolic, autoimmune, and infectious diseases more often than the general population.

CONCLUSIONS

The significant risk for postoperative cardiovascular and non-cardiovascular disease warrants close long-term follow-up after congenital heart surgery for all defects.

Design and methods for the training in exercise activities and motion for growth (TEAM 4 growth) trial: A randomized controlled trial

BACKGROUND

Growth is often impaired in infants with congenital heart disease. Poor growth has been associated with worse neurodevelopment, abnormal behavioral state, and longer time to hospital discharge. Nutritional interventions, drug therapy, and surgical palliation have varying degrees of success enhancing growth. Passive range of motion (PROM) improves somatic growth in preterm infants and is safe and feasible in infants with hypoplastic left heart syndrome (HLHS), after their first palliative surgery (Norwood procedure).

METHODS

This multicenter, Phase III randomized control trial of a 21-day PROM exercise or standard of care evaluates growth in infants with HLHS after the Norwood procedure. Growth (weight-, height- and head circumference-for-age z-scores) will be compared at 4 months of age or at the pre-superior cavopulmonary connection evaluation visit, whichever comes first. Secondary outcomes include neonatal neurobehavioral patterns, neurodevelopmental assessment, and bone mineral density. Eligibility include diagnosis of HLHS or other single right ventricle anomaly, birth at ≥37 weeks gestation and Norwood procedure at <30 days of age, and family consent. Infants with known chromosomal or recognizable phenotypic syndromes associated with growth failure, listed for transplant, or expected to be discharged within 14 days of screening are excluded.

CONCLUSIONS

The TEAM 4 Growth trial will make an important contribution to understanding the role of PROM on growth, neurobehavior, neurodevelopment, and BMD in infants with complex cardiac anomalies, who are at high risk for growth failure and developmental concerns.

The impact of the COVID-19 pandemic on application of European Society of Cardiology (ESC) guidelines for exercise in adults with CHD: a data-based questionnaire

INTRODUCTION

Regular physical activity is safe and effective therapy for adults with CHD and is recommended by European Society of Cardiology guidelines. The COVID-19 pandemic poses enormous challenges to healthcare teams and patients when ensuring guideline compliance. We explored the implications of COVID-19 on physical activity levels in adult CHD patients.

MATERIALS AND METHODS

A data-based questionnaire was distributed to adult CHD patients at a regional tertiary centre from October to November 2020.

RESULTS

Prior to the COVID-19 pandemic, 96 (79.3%) of 125 respondents reported participating in regular physical activity, with 66 (52.8%) meeting target levels (moderate physical activity for at least 150 minutes per week). Commonest motivations for physical activity were general fitness (53.6%), weight loss (36.0%), and mental health benefits (30.4%). During the pandemic, the proportion that met target levels significantly decreased from 52.8% to 40.8% (p = 0.03). The commonest reason was fear of COVID-19 (28.0%), followed by loss of motivation (23.2%) and gym/fitness centre closure (15.2%).

DISCUSSION

The COVID-19 pandemic has negatively impacted exercise levels of adult CHD patients. Most do not meet recommended physical activity levels, mainly attributable to fear of COVID-19. Even before the pandemic, only half of respondents met physical activity guidelines. Availability of online classes can positively impact exercise levels so could enhance guideline compliance. This insight into health perceptions and behaviours of adult CHD patients may help develop quality improvement initiatives to improve physical activity levels in this population.

Making every contact count: recognising obesity in paediatric and young adult cardiology

INTRODUCTION

With increased survival, children with CHD are reaching adulthood, however, obesity amongst this cohort is an emerging problem. Making every contact count encourages clinicians to utilise contact to elicit behaviour change. The aim of this work was to identify whether the body habitus of children classified as obese was addressed during a clinical review.

METHODS

A retrospective observational cohort study was completed using a cardiology outpatient dataset from 2010 to 2019. Inclusion criteria are all children with a body mass index z score classified as obese (≥ 2 z scores). Individual electronic patient records were reviewed to identify long-term anthropometric measures including (i) recognition of body habitus, (ii) prescription of physical activity or dietary intervention, and (iii) referral to a weight management programme or dietitian.

RESULTS

From the cohort of 95 patients, 285 "obese clinical encounters" were identified, at the time of a cardiology clinic attendance. Of those, obesity was acknowledged in 25 clinic letters (8.65%), but only 8 used the correct terms "obese" or "obesity" (2.77%). Action to tackle obesity was recorded in 9.3% of cases with a direct referral to a dietitian being made on 3 occasions (1.04%).

CONCLUSIONS

Body habitus is not being routinely addressed by cardiologists caring for paediatric and young adult cardiac patients. This study has recognised an alarmingly high incidence of missed opportunities to make every contact count, to manage those with obesity and associated risk factors.

The Effects of Physical Inactivity and Exercise at Home in Young Patients with Congenital Heart Disease during the COVID-19 Pandemic

Background: The COVID-19 pandemic had a significant impact on the population’s ability to be physically active. Purpose: Evaluate the effect of the COVID-19 mitigation measures on exercise tolerance in patients with congenital heart disease (CHD). Materials and methods: All subjects (880, 6–18 years old) who performed a stress test at our hospital from October 2020 to February 2021 and had a similar test one year earlier were enrolled. A questionnaire on the degree of physical activity carried out in 2020 concerning the period prior to the pandemic was compiled. Exercise tolerance and the main anthropometric parameters between the first and second tests were compared. Results: 110 subjects (11.9 ± 4.1 years) were included in the study. The percentage of patients engaged in regular physical activity (RPA) decreased significantly during the pandemic (p < 0.001), and BMI increased significantly (p < 0.001), except among the subjects who began RPA during the lockdown, whereas test duration did not decrease significantly overall but increased in this last subgroup (p < 0.05) Conclusions: The COVID-19 lockdown led to a less active lifestyle with a significant increase in BMI in our group of CHD. These data could have negative effects on the risk profile of this population. RPA practiced at home seems to be effective in counteracting such effects.

Inactive Lifestyles among Young Children with Innocent Murmurs or Congenital Heart Disease Regardless of Disease Severity or Treatment

BACKGROUND

Sedentary lifestyle morbidities are common among children with congenital heart disease (CHD). Understanding the physical activity trajectory from early childhood could enhance intervention timing/effectiveness.

METHODS

154 children (56% male) were recruited at 12-47 months of age for this prospective, longitudinal, observational study. Physical activity and sedentary behaviour (7-day accelerometry) and motor skill (Peabody Developmental Motor Scales-2) were assessed every 8 months until 5 years of age and then annually. Mixed effect repeated measures regression models described outcome trajectories across study assessments.

RESULTS

Children had an innocent heart murmur (n=28), CHD with insignificant hemodynamics not requiring treatment (n=47), CHD treated by catheterization or surgery without cardiopulmonary bypass (n=31), or CHD treated surgically with bypass (n=48). Motor skill was age appropriate (Peabody 49.0±8.4) but participants had lower physical activity (143±41 mins/day) and higher sedentary time (598±89 mins/day) than healthy peers, starting at 18 months of age. Movement behaviours were not related to treatment group (p>0.10), and physical activity was below the recommended 180 mins/day. Over time, physical activity, sedentary time and motor skill were primarily related to the baseline measure of each outcome (p<0.001).

CONCLUSIONS

Children with simple or complex CHD or innocent heart murmurs have an increased risk for sedentary lifestyles. Their physical activity and sedentary behaviours are established prior to 2 years of age, persist until school age, and are unrelated to motor skill. These results emphasize the need for interventions targeting the youngest children seen in a cardiac clinic, regardless of CHD diagnosis or innocent murmur.

Sizing Up Fontan Failure: Association with Increasing Weight in Adulthood

Obesity has become increasingly recognized in adults with Fontan palliation, yet the relationship between weight changes in adulthood and Fontan failure is not clearly defined. We hypothesize that increasing weight in adulthood among Fontan patients is associated with the development of Fontan failure. Single-center data from adults with Fontan palliation who were not in Fontan failure at their first clinic visit in adulthood and who received ongoing care were retrospectively collected. Fontan failure was defined as death, transplant, diagnosis of protein losing enteropathy, predicted peak VO₂ less than 50%, or new loop diuretic requirement. Anthropometric data including weight and BMI were collected. Change in weight was compared between those that developed Fontan failure, and those that remained failure-free. To estimate the association between weight change during adulthood and the risk of developing Fontan failure, a survival analysis using multiple Cox's proportional hazards regression model was performed. Overall, 104 patients were included in the analysis. Those that developed Fontan failure had a larger associated median weight gain than those who remained failure-free (7.8 kg vs. 4.9 kg, respectively; p = 0.011). In multivariable Cox regression analysis, increased weight during adulthood was associated with increased likelihood of developing Fontan failure (HR 1.36; CI 1.07-1.73; p = 0.011). Weight gain in adulthood is associated with the development of Fontan failure.

American College of Cardiology Body Mass Index Counseling Quality Improvement Initiative

Overweight/obesity, prevalent cardiovascular risk factors in children, can be associated with increased risk of adverse outcomes in children with heart disease. The American College of Cardiology (ACC) developed quality metrics including a BMI metric related to identifying and counseling overweight and obese children presenting to cardiology clinics. This metric was used for a multicenter collaborative learning Quality improvement (QI) Project through the ACC Quality Network (QNet). Our aim was to increase the percentage of children between ages 3 and 18 years presenting to cardiology clinics at participating centers with BMI > 85th percentile who received appropriate counseling. Participating centers submitted data quarterly to QNet for a sample of patients who received counseling. A Key Driver Diagram was created to help teams drive improvement. Individual centers customized interventions and participated in network-wide educational learning sessions about QI and shared experience. Statistical process control charts were used. From 04/01/2017 to 09/30/2019, 27,511 patient visits were included. Among 32 participating centers, overall counseling rate was 54%. The BMI counseling rate increased from 25% in 2017Q2 to 54% in 2019Q3. There was a wide variation from 10 to 100% in the performance of individual centers. The overall rate of identification and counseling of overweight and obese children presenting to ambulatory cardiology clinics in participating centers is low. There is wide variation in the performance of centers, providing an opportunity for improvement. Using this multicenter learning approach, individual centers have demonstrated improvement. This demonstrates that collaborative learning approaches in QI can increase implementation of the metric.

Metabolic syndrome and coronary artery disease in adults with congenital heart disease

In adults with congenital heart disease (ACHD), conditions acquired with aging, such as metabolic syndrome, hypertension, diabetes mellitus, and obesity, can negatively influence the original cardiovascular disease. Metabolic syndrome has a higher prevalence in ACHD than in the general population. In contrast, coronary artery disease shows a similar prevalence in adults with acyanotic CHD and the general population, while adults with cyanotic CHD, even after repair, have an even lower incidence of coronary artery disease than the general population/adults with acyanotic CHD. However, even in those with cyanotic CHD, coronary artery disease can develop when they have risk factors such as obesity, dyslipidemia, hypertension, diabetes mellitus, smoking habit, or limited exercise. The prevalence of risk factors for cardiovascular disease is similar between ACHD and the general population, but an increased risk of coronary atherosclerosis has been observed for congenital coronary artery anomalies, dextro-transposition of the great arteries after arterial switch operation, Ross procedure, and coarctation of the aorta. Aortopathy may be an additional risk factor for cardiovascular disease. As ACHD have other abnormalities that may make the heart more vulnerable to both the development of atherosclerosis and adverse cardiovascular sequelae, regular evaluation of their cardiovascular disease risk status is recommended. Metabolic syndrome is more common among ACHD than in the general population, and may therefore increase the future incidence of atherosclerotic coronary artery disease even in ACHD. Thus, ACHD should be screened for metabolic syndrome to eliminate risk factors for atherosclerotic coronary artery disease.

Perceptions of Healthy Lifestyles Among Children With Complex Heart Disease and Their Caregivers

Background

Children with complex heart problems may be at higher risk for sedentary lifestyle morbidities than their healthy peers. This project examined perceptions, barriers, and supports that influence healthy active lifestyles among children with complex heart problems and their caregivers, to enable effective health and quality-of-life interventions.

Methods

Inductive thematic analysis was conducted of semi-structured guided discussions from 6 focus groups (young child [n = 2]; older child [n = 4]; parents of young child [n = 4]; parents of older child [n = 4]; pediatric cardiologist [n = 5]; pediatric cardiac nurse [n = 5]) and individual interviews with 7 parents, 5 parent/child dyads, 2 adults with complex heart problems, 6 pediatric cardiologists, 3 pediatric cardiac nurses, 4 pediatric cardiology mental health professionals, and 14 recreation professionals.

Results

Four interrelated themes were identified: (i) "It takes a village"—coordinated and collaborative interdisciplinary support; (ii) clear healthy lifestyle communication among children, families, and professionals is critically important; (iii) Ccreating supportive environments by building professional expertise; (iv) inspiring healthy lifestyles in the children’s own environments. All groups identified a need to improve knowledge about childhood heart conditions among education and recreation professionals and to encourage effective communication between healthcare professionals and families. Participants indicated that these changes would support families, educators, and recreation professionals in engaging children with heart problems in healthy lifestyles in home, school, and community settings.

Conclusions

Important healthy lifestyle barriers were identified within individuals and in their interactions. There is a profound need to enhance knowledge of childhood heart conditions and improve interactions among key stakeholders—children and families, educators, and recreation and healthcare professionals.

Adherence with lipid screening guidelines in standard- and high-risk children and adolescents

Because atherosclerosis begins in childhood, universal lipid screening is recommended with special attention to conditions predisposing to early atherosclerosis. Data about real-world penetration of these guidelines is not available.

METHODS

Retrospective cohort study using MarketScan® commercial and Medicaid insurance claims databases, a geographically representative sample of U.S. children. Subjects who passed through the 9- to 11-year window and had continuous insurance coverage between 1/1/2013 and 12/31/2016 were studied. Multivariable models were calculated, evaluating the association between other patient factors and the likelihood of screening. The primary hypothesis was that screening rates would be low, but that high-risk conditions would be associated with a higher likelihood of screening.

RESULTS

In total, 572,522 children (51% male, 33% black, 11% Hispanic, 51% Medicaid) were studied. The prevalence of high-risk conditions was 2.2%. In unadjusted and adjusted analyses, these subjects were more likely to be screened than standard-risk subjects (47% vs. 20%, OR: 3.7, 95% CI 3.5-3.8, P < .001). Within this group, the diagnosis-specific likelihood of screening varied (26-69%). Endocrinopathies (OR 5.4, 95% CI 5.2-5.7), solid organ transplants (OR 5.0, 95% CI 3.8-6.6), and metabolic disease (OR 3.9, 95% CI 3.1-5.0, all P < .001) were associated with the highest likelihood of undergoing screening.

CONCLUSIONS

Despite national recommendations, lipid screening was performed in a minority of children. Though subjects with high-risk conditions had a higher likelihood of screening, rates remained low. This study highlights the need for research and advocacy regarding obstacles to lipid screening of children in the United States.

Obesity across the lifespan in congenital heart disease survivors: Prevalence and correlates

BACKGROUND

Congenital heart disease (CHD) survivors are at risk for cardiovascular comorbidities exacerbated by obesity.

OBJECTIVES

Determine relationships between overweight/obesity and medical factors across the lifespan of CHD.

METHODS

Lesion severity, weight, blood pressure, cardiac and other comorbidities, and cardiac medications were abstracted from the medical records of 3790 CHD patients, aged ≥6 years, who attended CHD care in the Midwestern U.S.

RESULTS

The proportion of patients with overweight/obesity increased across the lifespan, with 73% of adults affected by overweight/obesity. Obesity was more prevalent among patients with moderate lesions (29%). Overweight/obesity was associated with elevated blood pressure across age and lesion severity. Young adults with obesity and simple or moderate lesions had more comorbidities (simple: IRR = 3.1, moderate: IRR = 2.3) and cardiac medications (simple: IRR = 2.2, moderate: IRR = 1.7).

CONCLUSIONS

Obesity and its cardiovascular correlates are present across the lifespan for CHD survivors, highlighting the need for early prevention and intervention.

"I really like playing games together": Understanding what influences children with congenital heart disease to participate in physical activity

BACKGROUND

Participation in physical activity is essential to the long-term health and development of all children. However, children living with cardiac conditions are typically not active enough to sustain positive health outcomes. Understanding the experiences of children living with congenital heart disease in community-based settings could help inform the physical activity counselling practices of clinicians. The current study explored the perceptions of 7- to 10-year-old children with moderate or complex congenital heart disease as they participated in a 10-week multisport programme.

METHODS

Detailed field notes recorded the discussions and behaviours of 11 participants (45% female participants) each week during the programme sessions. Among those, four participants (50% female participants) were purposively selected to participate in preprogramme and postprogramme focus groups to gather more detailed accounts of their experiences.

RESULTS

Four main themes surrounding physical activity were identified: (a) motivation, (b) self-efficacy, (c) peer influences, and (d) family influences. Although feelings of excitement and enjoyment towards physical activity were prevalent throughout the data ("I'm really excited … because I really like those sports"), participants also often felt frustrated, nervous, and fatigued ("I'm not very good at the skills"). Social inclusion with peers and family influences were meaningful reasons to engage in physical activity ("I really like playing games together"). Following the completion of the programme, participants emphasized their enjoyment of physical activity as a primary source of motivation, demonstrating an important shift from recognizing positive health outcomes ( "… it's good for you") towards more intrinsic sources of motivation ("… because it's fun").

CONCLUSION

Opportunities for physical activity that enhance positive experiences and build intrinsic motivation should be identified and promoted to children with congenital heart disease. Community-based programmes may also be an appropriate context for children with cardiac conditions to engage and maintain participation in physical activity through adolescence.

Added sugar and trans fatty acid intake and sedentary behavior were associated with excess total-body and central adiposity in children and adolescents with congenital heart disease

BACKGROUND

Over the past three decades, the prevalence rate of overweight and obesity has increased in survivors with congenital heart disease, and little is known about the body composition and its association with clinical characteristics and lifestyle factors.

OBJECTIVES

To evaluate excess total-body adiposity and central adiposity and, to describe associated factors.

METHODS

Cross-sectional study with children and adolescents who underwent procedure to treat congenital heart disease, from January to July 2017. Sociodemographic and clinical characteristics, and lifestyle factors (dietary intake, physical activity, and sedentary behavior) were assessed. Adiposity was assessed using air-displacement plethysmography and waist circumference. Factors associated with excess total-body adiposity and central adiposity were analyzed using logistic regression models.

RESULTS

Of 232 patients, 22.4% were identified with excess total-body adiposity and 24.6% with central adiposity. Significant factors positively associated with excess total-body adiposity were intake of added sugar and trans fatty acids, adjusted for confounding factors. Similarly, lifestyle factors were positively associated with central adiposity: intake of added sugar and trans fatty acids, sedentary behavior, and family history of obesity.

CONCLUSIONS

Lifestyle factors were associated with excess total-body adiposity and central adiposity. Assessment of body composition and healthy-lifestyle counseling into outpatient care may be the key point to prevent obesity in children and adolescents with congenital heart disease.

Chronic Disease Burden After Congenital Heart Surgery: A 47-Year Population-Based Study With 99% Follow-Up

Background Postoperative morbidity is an increasingly important outcome measure of patients who have undergone congenital heart surgery (CHS). We examined late postoperative morbidity after CHS on the basis of patients' government-issued medical special reimbursement rights. Methods and Results Between 1953 and 2009, 10 635 patients underwent CHS at <15 years of age in Finland. We excluded early deaths and mental disabilities. Noncyanotic and cyanotic defects were divided into simple and severe groups, respectively. We obtained 4 age-, sex-, birth time-, and hospital district-matched control subjects per patient. The Social Insurance Institution of Finland provided data on all medical special reimbursement rights granted between 1966 and 2012. Follow-up started at the first operation and ended at death, date of emigration, or December 31, 2012. A total of 8623 patients met inclusion criteria. Follow-up was 99.9%. A total of 3750 patients (43%) required special reimbursements rights for a chronic disease. Cardiovascular disease was the most common late morbidity among patients (28%), followed by obstructive pulmonary disease (9%), neurologic disease (3%), and psychiatric disease (2%). Heart failure (simple hazard ratio [HR], 56.3 [95% CI, 35.4-89.7]; severe HR, 918.0 [95% CI, 228.9-3681.7]) and arrhythmia (simple HR, 11.0 [95% CI, 7.1-17.0]; severe HR, 248.0 [95% CI, 61.3-1002.7]) were the most common cardiovascular morbidities. Hypertension was common among patients with coarctation of the aorta (13%; incidence risk ratio [RR], 8.9; 95% CI, 7.5-10.7). Psychiatric disease was more common among simple defects, particularly ventricular septal defects. Conclusions Chronic cardiac and noncardiac sequelae are common after CHS regardless of the severity of the defect, underscoring the importance of long-term follow-up of all patients after CHS.

Impacting child health outcomes in congenital heart disease: Cluster randomized controlled trial protocol of in-clinic physical activity counselling

BACKGROUND

Most (>90%) children with congenital health defects are not active enough for optimal health. Proactively promoting physical activity during every clinic visit is recommended, but rarely implemented due to a lack of appropriate resources.

METHODS

This cluster randomized controlled trial will implement an evidence-based, multi-faceted physical activity intervention. All eligible patients at small (London, ON), medium (Ottawa, ON) and large (Edmonton, AB) pediatric cardiac clinics will be approached, with randomization to intervention/control by clinic and week. Intervention patients will be counselled with 5 key physical activity messages, have questions about physical activity answered, and have access to a custom web site with personalized activity suggestions and support from a Registered Kinesiologist. The primary outcome is daily physical activity (number of steps, minutes of moderate-to-vigorous activity) assessed via pedometer one week per month for 6-months. Standardized questionnaires assess activity motivation and quality of life at baseline and end of study. Healthcare outcomes will be clinic visit time and contacts for physical activity concerns. Repeated measures ANCOVA will compare control/intervention pedometer outcomes, adjusting for covariates (alpha=0.05).

CONCLUSIONS

This trial aims to determine whether providing resources and protocols enables clinicians to counsel about physical activity as part of every pediatric cardiology appointment. Evaluations of healthcare system impact and intervention delivery in small, medium and large clinics will assess applicability for implementation in all pediatric cardiac clinics. The impact on physical activity motivation and participation will evaluate the effectiveness of this standardized approach for increasing physical activity in children with congenital heart defects.

Metabolic Syndrome in Adult Congenital Heart Disease

In adult congenital heart disease (ACHD), residua and sequellae after initial repair develop late complications such as cardiac failure, arrhythmias, thrombosis, aortopathy, pulmonary hypertension and others. Acquired lesions with aging such as hypertension, diabetes mellitus, obesity can be negative influence on original cardiovascular disease (CVD). Also, atherosclerosis may pose an additional health problem to ACHD when they grow older and reach the age at which atherosclerosis becomes clinically relevant. In spite of the theoretical risk of atherosclerosis in ACHD due to above mentioned factors, cyanotic ACHDs even after repair are noted to have minimal incidence of coronary artery disease (CAD). Acyanotic ACHD has similar prevalence of CAD as the general population. However, even in cyanotic ACHD, CAD can develop when they have several risk factors for CAD. The prevalence of risk factor is similar between ACHD and the general population. Risk of premature atherosclerotic CVD in ACHD is based, 3 principal mechanisms: lesions with coronary artery abnormalities, obstructive lesions of left ventricle and aorta such as coarctation of the aorta and aortopathy. Coronary artery abnormalities are directly affected or altered surgically, such as arterial switch in transposition patients, may confer greater risk for premature atherosclerotic CAD. Metabolic syndrome is more common among ACHD than in the general population, and possibly increases the incidence of atherosclerotic CAD even in ACHD in future. Thus, ACHD should be screened for metabolic syndrome and eliminating risk factors for atherosclerotic CAD.

Cardiometabolic risk in obese children

Obesity in childhood remains a significant and prevalent public health concern. Excess adiposity in youth is a marker of increased cardiometabolic risk (CMR) in adolescents and adults. Several longitudinal studies confirm the strong association of pediatric obesity with the persistence of adult obesity and the future development of cardiovascular disease, diabetes, and increased risk of death. The economic and social impact of childhood obesity is further exacerbated by the early onset of the chronic disease burden in young adults during their peak productivity years. Furthermore, rising prevalence rates of severe obesity in youth from disadvantaged and/or minority backgrounds have prompted the creation of additional classification schemes for severe obesity to improve CMR stratification. Current guidelines focus on primary obesity prevention efforts, as well as screening for clustering of multiple CMR factors to target interventions. This review summarizes the scope of the pediatric obesity epidemic, the new severe obesity classification scheme, and examines the association of excess adiposity with cardiovascular and metabolic risk. We will also discuss potential questions for future investigation.

A diet high in sugar-sweetened beverage and low in fruits and vegetables is associated with adiposity and a pro-inflammatory adipokine profile

Diet, obesity and adipokines play important roles in diabetes and CVD; yet, limited studies have assessed the relationship between diet and multiple adipokines. This cross-sectional study assessed associations between diet, adiposity and adipokines in Mexican Americans. The cohort included 1128 participants (age 34·7±8·2 years, BMI 29·5±5·9 kg/m2, 73·2 % female). Dietary intake was assessed by 12-month food frequency questionnaire. Adiposity was measured by BMI, total percentage body fat and percentage trunk fat using dual-energy X-ray absorptiometry. Adiponectin, apelin, C-reactive protein (CRP), dipeptidyl peptidase-4 (DPP-IV), IL-1β, IL-1ra, IL-6, IL-18, leptin, lipocalin, monocyte chemo-attractant protein-1 (MCP-1), resistin, secreted frizzled protein 4 (SFRP-4), SFRP-5, TNF-α and visfatin were assayed with multiplex kits or ELISA. Joint multivariate associations between diet, adiposity and adipokines were analysed using canonical correlations adjusted for age, sex, energy intake and kinship. The median (interquartile range) energy intake was 9514 (7314, 11912) kJ/d. Overall, 55 % of total intake was accounted for by carbohydrates (24 % from sugar). A total of 66 % of the shared variation between diet and adiposity, and 34 % of diet and adipokines were explained by the top canonical correlation. The diet component was most represented by sugar-sweetened beverages (SSB), fruit and vegetables. Participants consuming a diet high in SSB and low in fruits and vegetables had higher adiposity, CRP, leptin, and MCP-1, but lower SFRP-5 than participants with high fruit and vegetable and low SSB intake. In Mexican Americans, diets high in SSB but low in fruits and vegetables contribute to adiposity and a pro-inflammatory adipokine profile.

[Overweight and obesity in children treated for congenital heart disease]

INTRODUCTION

The negative impact of overweight and obesity is potentially greater in children affected by a congenital heart disease (CHD). The aim of this study is to calculate the proportion of overweight and obesity in children who underwent an intervention for CHD, and to investigate systolic arterial hypertension as a possible early cardiovascular complication.

PATIENTS AND METHODS

A retrospective study was conducted on patients aged 6-17 years treated for CHD, and healthy control subjects, followed-up in a Paediatric Cardiology Clinic. Body mass index percentiles were calculated according to the criteria of WHO. A review was performed on the anthropometric and clinical data, as well as the systolic blood pressure (SBP).

RESULTS

A total of 440 patients were included, of which 220 had CHD. The proportion of combined obesity and overweight (body mass index percentile ≥85) was 36.4% (37.3% in healthy subjects and 35.4% in patients with CHD, P=.738). A higher prevalence of obesity (body mass index percentile ≥97) was found in CHD patients (22.7%) compared to 15.5% in healthy subjects (P=.015). SBP percentiles were higher in overweight compared to normal-weight patients (P < .001). The prevalence of SBP readings ≥ the 95th percentile was greater in overweight than in normal weight CHD patients (29.5% versus 7.7%, P < .001) and also in the overweight healthy controls compared to those of normal weight (12.2% versus 0.7%, P < .001).

CONCLUSIONS

The proportion of obesity is high in children treated for CHD and it is associated with elevated SBP levels. The risk of long-term complications needs to be reduced by means of prevention and treatment of obesity in this vulnerable population.

Eating with others and meal location are differentially associated with nutrient intake by sex: The Diabetes Study of Northern California (DISTANCE)

Though eating with others is often a social behavior, relationships between social contexts of eating and nutrient intake have been underexplored. This study evaluates how social aspects of eating - frequencies of eating meals with others, meals prepared at home, and meals outside the home - are associated with nutrient intake. Because diet improvement can reduce complications of diabetes mellitus, we surveyed a multi-ethnic cohort of persons with type 2 diabetes (n = 770) about social aspects of diet (based on 24-hour recalls). Sex-stratified multiple regression analyses adjusted for confounders assessed the relationship between frequency of eating with others and nutrient intake (total energy, energy from fat, energy from carbohydrates, Healthy Eating Index/HEI, Dietary Approaches to Stop Hypertension/DASH score). Although there was slight variation in men's versus women's propensity to share meals, after adjustment for confounders, there was no consistently significant association between meals with others and the 5 nutrient intake measures for either men or women. The directions of association between categories of eating with others and diet quality (HEI and DASH scores) - albeit not significant - were different for men (positive) and women (mostly negative), which warrants further investigation. The next analyses estimated nutrient intake associated with meals prepared at home, and meals consumed outside the home. Analyses indicated that greater meal frequency at home was associated with significantly better scores on diet quality indices for men (but not women), while meal frequency outside the home was associated with poorer diet quality and energy intake for women (but not men). Better measurement of social dimensions of eating may inform ways to improve nutrition, especially for persons with diabetes for whom diet improvement can result in better disease outcomes.

Frequency of Guideline-Based Statin Therapy in Adults With Congenital Heart Disease

We aimed to evaluate atherosclerotic cardiovascular disease (ASCVD) risk estimates and guideline-based statin use for primary prevention of ASCVD in adults with congenital heart disease (ACHD). This was a case-controlled, retrospective study of 248 cases and 744 age- and gender-matched controls at a tertiary care referral center. ASCVD risk scores were calculated and used to assess indication for statin treatment for primary prevention per the 2013 American College of Cardiology and American Heart Association guideline on assessment of cardiovascular risk. There were no differences in average 10-year ASCVD risk scores between ACHD cases (4.6% ± 6.6%) and matched controls (5.1% ± 6.7%, p = 0.32). ACHD cases had lower total cholesterol (183 ± 38 vs 192.6 ± 35.3 mg/dL, p < 0.001) and were less likely to smoke (8.1% vs 14.6%, p = 0.008), yet had lower high density lipoprotein (52.6 ± 17.2 vs 55.3 ± 17.1 mg/dL, p = 0.03) and higher hypertension rates (38.7% vs 28.5%, p = 0.003). However, only 42.3% ACHD cases with a primary prevention statin indication were appropriately prescribed therapy as compared with 59.0% of controls (p = 0.04). In conclusion, ACHD cases have a similar 10-year ASCVD risk score than age- and gender-matched peers, but ACHD cases are less likely than their peers to be prescribed statin therapy for primary prevention per guideline-based recommendations.