Assembling evidence to justify prevention of atherosclerosis beginning in youth.

Atherosclerosis begins in youth when the earliest lesions, fatty streaks, can be identified in the arterial beds of most adolescents. Rapid progression of these early lesions to fibrous plaques occurs in the third and fourth decades of life, with the rate of progression directly associated with the number of cardiovascular risk factors.1,2 The presence of atherosclerosis early in life, its relationship at a young age to the major cardiovascular risk factors, and its steady progression toward cardiovascular events later in life have suggested to many that the optimal age to begin atherosclerosis prevention is as young as possible. Article see p 2514 However, the various strategies proposed to achieve early prevention remain highly controversial. What is the best age to begin (the range considered in the literature is from conception to young adulthood)? Should efforts be limited to those at the highest risk (eg, patients with familial hypercholesterolemia or youth onset diabetes) or directed toward the entire population? Is there evidence that any such strategies are effective, and, most importantly, what are the legitimate study designs and end points to establish that evidence? Are randomized trials the only strategy to establish that evidence base, and are the only appropriate endpoints prevention of cardiovascular events, or is the demonstration of the prevention of atherosclerosis sufficient? Certain to be cited as support for every possible stance in the youth prevention debate is the paper by Juonala et al3 in this issue of Circulation , in which results from 4 different longitudinal studies from the United States, Finland, and Australia are pooled to demonstrate the relationship among risk factors measured in youth and carotid intima-media …