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About: Atherosclerosis in its earliest stages is associated with the same traditional cardiovascular disease (CVD) risk factors as are associated with manifest CVD events in adulthood. Clustering of risk factors is associated with exponential increases in atherosclerotic burden from a young age. Some medical conditions and risk behaviors occurring in children can either increase the likelihood of higher levels of risk factors (such as chronic kidney disease) or the presence of risk factor clustering (such as obesity and cardiometabolic syndrome), or are associated with acquired coronary artery pathology (such as Kawasaki disease). This creates a milieu for, or increases the impact of, accelerated atherosclerosis that in turn increases the likelihood of premature CVD. This review highlights the importance of considering the total risk factor and risk condition profile of pediatric patients. An algorithm is provided for stratifying patients into high, moderate and at risk categories, and practical examples are provided as to how the evaluation and management of one risk factor or risk condition might need to be intensified in the context of additional risk factors or risk conditions. For example, for treatment of an adolescent with familial hypercholesterolemia, the target low-density lipoprotein cholesterol level might be lowered by the concomitant presence of low high-density lipoprotein cholesterol or elevated lipoprotein(a) levels. As awareness of cardiovascular risk and atherosclerosis in pediatric patients increases, new at risk conditions that warrant consideration are emerging. The identification and management of high risk individuals is an important part of the overall practice of pediatric preventive cardiology.

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