In a study published November 11 in the British Medical Journal, a group of cardiologists based in the Netherlands calls for scaling back the controversial American Heart Association and American Academy of Pediatrics guidelines for treating kids with high cholesterol (see here and here).

The AHA and AAP guidelines differ slightly but both call for treating kids with medication if their LDL ("bad") cholesterol is over 190 with no other risk factors, or over 160 with other risk factors. The guidelines also recommend that treatment start at age 8 (AAP guidelines) or, in the case of the AHA guidelines, age 10 in boys or after menses in girls.

The guidelines are in part based on a number of clinical trials of statins in kids with heterozygous familial hypercholesterolemia (heFH), a genetic disorder in which LDL ("bad") cholesterol levels are extremely high. Statins have been shown to slow atherosclerosis in kids with heFH. But the AAP and AHA guideline-writers extrapolated from that to apply it to kids with high cholesterol due to obesity and other factors.

The study concludes that moderate doses of statins reduce the risk of developing heart disease by 76 percent in adult patients with heFH. The study compared patients who started taking a statin immediately when statins entered the market in the Netherlands in the late 1980s with those who started taking one an average of 4.3 years later. Women and men experienced similar benefits. The risk of heart attack in patients older than 55 treated with statins was still 44 percent higher than in the general population. However, this contrasts with the risk for patients with untreated heFH in that age group, for whom the risk of heart attack is almost 9 times higher than in normal persons. The results suggest that statin treatment has greatly reduced the risk of heart attacks in patients with heFH.

A 76 percent risk reduction from moderate doses of statins is much higher than has been found in the primary prevention trials of statins. These trials, which did not include heFH patients for ethical reasons, have generally found a risk reduction of 25 to 30 percent.

As a result of this larger than expected risk reduction, the authors conclude that patients with heFH should start treatment in early adulthood rather than in childhood, with the exception of children with a parent or sibling with very early heart disease. They reason that, although children with heFH have signs of early atherosclerosis, this condition is reversible if treatment is started in early adulthood.

Let's hope the guideline writers take note of this study and the views of these researchers. If it is not necessary to treat most kids with heFH starting in childhood, I believe most other kids covered by the guidelines can safely wait until adulthood as well.

-- Marilyn Mann