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Canadian Journal of Cardiology

The Rationale, Indications, Safety, and Use of Statins in the Pediatric Population

  • Michael Khoury
    Correspondence
    Corresponding author: Dr Michael Khoury, Department of Pediatrics, Stollery Children’s Hospital, 8440-112th Street NW, Edmonton, Alberta T6G 2B7, Canada. Tel.: +1-780-407-8361; fax: +1-780-407-3954.
    Affiliations
    Division of Pediatric Cardiology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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  • Brian W. McCrindle
    Affiliations
    Labatt Family Heart Center, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Published:April 05, 2020DOI:https://doi.org/10.1016/j.cjca.2020.03.041

      Abstract

      Together with heart-healthy lifestyle habits, statins serve as the cornerstone of primary and secondary prevention of atherosclerotic cardiovascular disease in adults. Several conditions, most notably familial hypercholesterolemia (FH), cause early dyslipidemia and vascular disease, contributing to the development and progression of atherosclerosis from childhood and increased cardiovascular risk. In recent decades, studies increasingly have evaluated the safety and efficacy of statins in such high-risk youth. The strongest evidence for pediatric statin use is for the heterozygous FH population, whereby statin use has been shown to lower low-density lipoprotein cholesterol effectively, slow the progression of atherosclerosis and vascular dysfunction, and significantly reduce cardiovascular risk in early adulthood. Numerous meta-analyses and Cochrane reviews have demonstrated that attributed adverse effects, including liver toxicity, myositis, and rhabdomyolysis, occur no more frequently in youth receiving statins than placebos, with no impact on growth or development. However, further studies evaluating the long-term safety of pediatric statin use are required. In the current review, we summarize the pediatric experience of statin use to date, focusing on its utility for FH, Kawasaki disease, post-heart transplantation, and other at-risk populations. Current guidelines and indications for use are summarized, and the short- and medium-term safety experience is reviewed. Finally, a clinical approach to the indications, initiation, and monitoring of statins in youth is provided.

      Résumé

      Conjointement aux habitudes de vie favorables à la santé cardiovasculaire, les statines représentent la pierre angulaire de la prévention primaire et secondaire de la maladie cardiovasculaire athérosclérotique chez les adultes. Plusieurs maladies, plus particulièrement l’hypercholestérolémie familiale (HF), causent précocement une dyslipidémie et une maladie vasculaire, qui contribuent au développement et à la progression de l’athérosclérose de l’enfance et un risque cardiovasculaire accru. Au cours des dernières décennies, les études portaient de plus en plus sur l’évaluation de l’innocuité et de l’efficacité des statines chez les jeunes exposés à ce risque élevé. Les preuves les plus solides sur l’utilisation des statines en pédiatrie sont celles des populations hétérozygotes atteintes de HF, chez qui l’utilisation des statines a démontré abaisser efficacement les lipoprotéines de faible densité, ralentir la progression de l’athérosclérose et la dysfonction vasculaire, en plus de réduire significativement le risque cardiovasculaire au début de l’âge adulte. De nombreuses méta-analyses et revues Cochrane ont démontré que les effets défavorables qui y sont attribués sont entre autres l’hépatotoxicité, la myosite et la rhabdomyolyse, qui ne surviennent pas plus fréquemment chez les jeunes qui reçoivent des statines que chez ceux qui reçoivent les placebos, et qu’elles n’ont pas de répercussions sur la croissance ou le développement. Toutefois, des études plus poussées qui porteront sur l’évaluation de l’innocuité à long terme de l’utilisation des statines en pédiatrie sont nécessaires. Dans la revue actuelle, nous résumons l’expérience de l’utilisation des statines en pédiatrie jusqu’à ce jour et nous nous penchons principalement sur son utilité lors de HF, de la maladie de Kawasaki, de la post-transplantation cardiaque et sur d’autres populations exposées au risque. Nous résumons les lignes directrices actuelles et les indications quant à leur utilisation et passons en revue l’expérience sur l’innocuité à court et à moyen terme. Finalement, nous proposons une approche clinique en matière d’indications, d’introduction et de surveillance des statines chez les jeunes.
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