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Original Investigation |

Application of Pediatric and Adult Guidelines for Treatment of Lipid Levels Among US Adolescents Transitioning to Young Adulthood

Holly C. Gooding, MD, MSc1; Angie Mae Rodday, MSc2; John B. Wong, MD3; Matthew W. Gillman, MD, SM4; Donald M. Lloyd-Jones, MD, ScM5; Laurel K. Leslie, MD, MPH2; Sarah D. de Ferranti, MD, MPH6
[+] Author Affiliations
1Division of Adolescent/Young Adult Medicine, Boston Children’s Hospital, Boston, Massachusetts
2Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
3Division of Clinical Decision Making, Tufts Medical Center, Boston, Massachusetts
4Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts
5Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
6Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
JAMA Pediatr. 2015;169(6):569-574. doi:10.1001/jamapediatrics.2015.0168.
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Importance  Health care practitioners who care for adolescents transitioning to adulthood often face incongruent recommendations from pediatric and adult guidelines for treatment of lipid levels.

Objective  To compare the proportion of young people aged 17 to 21 years who meet criteria for pharmacologic treatment of elevated low-density lipoprotein cholesterol (LDL-C) levels under pediatric vs adult guidelines.

Design, Setting, and Participants  We performed a cross-sectional analysis of the National Health and Nutrition Examination Survey (NHANES) population. Surveys were administered from January 1, 1999, through December 31, 2012, and the analysis was performed from June through December 2014. Participants included 6338 individuals aged 17 to 21 years in the United States.

Main Outcomes and Measures  To estimate the number and proportion of individuals aged 17 to 21 years in the NHANES population who were eligible for statin therapy, we applied treatment algorithms from the 2011 Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents of the National Heart, Lung, and Blood Institute and the 2013 Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults from the American College of Cardiology and American Heart Association. After imputing missing data and applying NHANES sampling weights, we extrapolated the results to 20.4 million noninstitutionalized young people aged 17 to 21 years living in the United States.

Results  Of the 6338 young people aged 17 to 21 years in the NHANES population, 2.5% (95% CI, 1.8%-3.2%) would qualify for statin treatment under the pediatric guidelines compared with 0.4% (95% CI, 0.1%-0.8%) under the adult guidelines. Participants who met pediatric criteria had lower mean (SD) LDL-C levels (167.3 [3.8] vs 210.0 [7.1] mg/dL) but higher proportions of other cardiovascular risk factors, including hypertension (10.8% vs 8.4%), smoking (55.0% vs 23.9%), and obesity (67.7% vs 18.2%) compared with those who met the adult guidelines. Extrapolating to the US population of individuals aged 17 to 21 years represented by the NHANES sample, 483 500 (95% CI, 482 100-484 800) young people would be eligible for treatment of LDL-C levels if the pediatric guidelines were applied compared with only 78 200 (95% CI, 77 600-78 700) if the adult guidelines were applied.

Conclusions and Relevance  Application of pediatric vs adult guidelines for lipid levels, which consider additional cardiovascular risk factors beyond age and LDL-C concentration, might result in statin treatment for more than 400 000 additional adolescents and young adults.

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Algorithm for Recommending Statin Treatment to Adolescents and Young Adults Aged 17 to 21 Years in the National Health and Nutrition Examination Surveys (NHANES) Sample

The NHANES sample was accrued from January 1, 1999, through December 31, 2012. ACC-AHA indicates American College of Cardiology and American Heart Association; ASCVD, atherosclerotic cardiovascular disease; BMI, body mass index (calculated as weight in kilograms divided by height in meters squared); BP, blood pressure; DBP, diastolic BP; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol; NHLBI, National Heart, Lung, and Blood Institute; and SBP, systolic BP. To convert cholesterol to millimoles per liter, multiply by 0.0259.

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