Issue 2

Winter 2003

Testing CVD Screening Guidelines for Children at Risk

An epidemiological study of cardiovascular disease (CVD) risk factors in West Virginia school children indicates that the high CVD mortality rates in Central Appalachia's adult population are likely to continue unabated into the next generation. The study also suggests ways that universal, school-based screening can improve current guidelines for detecting children at risk for heart disease.

The Atlas of United States Mortality illustrates the problem in alarming shades of red: Central Appalachia rivals the Mississippi Delta and other pockets of the deep South as the "Heart Disease Capital of the United States." Central Appalachia includes West Virginia, Kentucky, and southern Ohio. Much of the region is rural.

"What Central Appalachia holds in common with these other centers of CVD mortality is long-term, wide-spread poverty. Compared to the rest of the U.S., West Virginia has one of the lowest median incomes and highest unemployment and poverty rates," explains Ellen Demerath, Ph.D., an epidemiologist at Wright State University's Lifespan Health Research Center.

Demerath evaluated CARDIAC, an acronym for Coronary Artery Risk Detection in Appalachian Communities. Funded by a $70,000 grant from the American Heart Association Ohio Valley Affiliate, her research was conducted in collaboration with pediatric cardiologist William Neal, M.D., and other colleagues at West Virginia University School of Medicine.

"We hypothesized that in this high-risk community, a more population-based approach, using the public schools as an entry point, might be a more effective tool to identify children at risk," Demerath says.

During the 2000-2001 school year, the CARDIAC program screened 1,478 fifth-grade public school children in 14 randomly selected rural counties in West Virginia. Close cooperation with school teachers and parents was needed to conduct the screenings, which also were offered to parents. Screenings involved a finger-stick blood sample for total cholesterol and HDL cholesterol, a blood pressure measurement, height and weight measurements, smoking exposure in the home, and family history of heart disease. A subset of 400 parents also completed questionnaires regarding economic status, cholesterol awareness and health knowledge.

Prevalence of CVD Risk Factors

16% of children had elevated systolic or diastolic blood pressure, meaning a systolic or diastolic pressure above the 95th percentile for their age, sex, and height. 25% of children had either total cholesterol greater than 200 mg/dl, or HDL less than 35 mg/dl. These children were re-tested using fasting blood draws to confirm dyslipidemia. Nearly half of the children in this sample were overweight or obese using the body mass index (BMI), which is a ratio of weight to height.

In addition to documenting the prevalence of CVD risk factors in children (see box), CARDIAC tested the effectiveness of national guidelines that recommend selective screening of children for high cholesterol. Based on the National Cholesterol Education Panel (NCEP) expert reports, current guidelines indicate testing children for lipid and lipoprotein risk factors only if there is a family history of premature CVD; if either parent is known to have a cholesterol concentration above 240 mg/dl; or if the parents' cholesterol status is unknowable, as in the case of adoption.


CARDIAC results indicate several limitations to the effectiveness of selective screening:

Of the 425 parents in the CARDIAC sub-study, 64% reported having their cholesterol level checked, but only 21% knew what their cholesterol concentration was, or whether it was above or below 240 mg/dl. According to Demerath, "This indicates that parents in this community will not be able to provide the necessary information to their child's pediatrician, as assumed by NCEP guidelines."

Of the 84 parents who reported being told by a physician that they had high cholesterol, only 12% of their children had been tested, which is no greater than the proportion of children tested in the rest of the study.

"The indication here is that even when parents know their cholesterol concentration is elevated, this does not initiate pediatric screening as recommended," Demerath says.

Among all the CARDIAC study children who were found to have confirmed dyslipidemia, only 21% of them had a positive family history of premature cardiovascular disease.

"Family history has a low sensitivity for predicting children with elevated blood cholesterol concentrations and will miss the vast majority of dyslipidemic children," Demerath says.

CARDIAC's universal, school-based approach to cholesterol screening has several advantages compared to selective screening, according to Demerath (see box). Significant among them is the "reverse detection" of dyslipidemia in adults who are at more immediate risk of heart disease. Of the 79 parents whose children had high total cholesterol and/or low HDL, and who chose to be tested, 66% were found to have previously undetected dyslipidemia themselves.

"These results suggest an alternative to the NCEP guidelines may be needed in this region where parental cholesterol awareness is low, family history is not highly informative, and access to health care is often limited," Demerath concludes.

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