The n e w e ng l a n d j o u r na l of m e dic i n e

Research Summary

Childhood Cardiovascular Risk Factors and Adult Cardiovascular Events

Jacobs DR Jr. et al. DOI: 10.1056/NEJMoa2109191

Clinical Problem Hazard Ratios for Adult Cardiovascular Events

Cardiovascular risk factors in childhood are known to According to Childhood Risk Factors
predict subclinical cardiovascular events in adulthood, Fatal Event Fatal or Nonfatal Event
but links to clinical events are lacking. 3

Hazard Ratio
2
Clinical Trial 1.61 1.70
1.44 1.45 1.50 1.45
1.30 1.31 1.34 1.33
Design: This prospective cohort study examined five com-
mon cardiovascular risk factors — body-mass index, sys- 1
tolic blood pressure, total cholesterol level, triglyceride
level, and smoking status — among 38,589 participants 0
3 to 19 years of age. These five risk factors were analyzed Body-mass Cholesterol Triglycerides Systolic blood Youth
to create age- and sex-standardized z scores. Childhood index level pressure smoking
and adult combined-risk z scores were also calculated. z Score Yes vs. No
Outcomes: Study outcomes included adult fatal cardiovas-
cular events and a composite of fatal or nonfatal cardio- Adult Events and Childhood Risk Factors
vascular events. in High-Normal or High-Acceptable Range
Fatal Event Fatal or Nonfatal Event
3
Results Childhood measurements Childhood measurements
in the high-normal range in the high-acceptable range
Cardiovascular Events: During a mean follow-up of 35 years,
Hazard Ratio

2
each stepwise increase in z score in childhood was asso- 1.59
1.46 1.42 1.34
ciated with an increased risk of fatal cardiovascular 1.01
1.19
events and of the composite outcome of fatal or nonfatal 1
cardiovascular events in adulthood. When all risk factors
were combined into a single unweighted z score, the risk
0
of cardiovascular events was even higher. In addition, the Body-mass Systolic blood Triglycerides
adult combined-risk z score was associated with adult index pressure
cardiovascular events both alone and when paired with
the childhood combined-risk z score. Hazard Ratios According to Adult Combined-Risk z Score
Fatal Event Fatal or Nonfatal Event
Risk-Factor Categories and Thresholds: Even some risk
factors that were mildly elevated but still in the normal 4
3.20
range were associated with increased cardiovascular risk. (95% CI, 2.46–4.17) 2.88
3 (95% CI, 2.47–3.35)
Hazard Ratio

Limitations and Remaining Questions 2

∎ Approximately 46% of the participants could not be lo- 1

cated to ascertain nonfatal cardiovascular events in
adulthood — a potential response bias.
∎ The number of non-White participants in the study
was limited, which potentially affects the generaliz-
ability of the findings.
∎ Although the unweighted risk scores facilitated the
analysis, they may not improve risk prediction across
the life course.
Links: Full Article | NEJM Quick Take | Editorial
0
Combined-Risk z Score
CONCLUSIONS
Five known cardiovascular risk factors — body-mass index,
systolic blood pressure, total cholesterol level, triglyceride
level, and youth smoking — especially when combined,
were associated with adult cardiovascular events and death
from cardiovascular causes before the age of 60 years.