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Lipoprotein(a) (Lp(a)) is made up of apoprotein(a) (apo(a)) and an LDL-like particle. The LPA gene encodes apo(a) and thus determines the characteristics and amount of apo(a) and Lp(a). The proportion of Lp(a) in each individual is genetically determined and is only minimally modifiable by the environment or diet. Lp(a) has important pro-atherosclerotic and pro-inflammatory effects. It has been hypothesized that Lp(a) also has pro-coagulant and antifibrinolytic actions. For these reasons, high Lp(a) values are an important independent risk factor for cardiovascular disease and calcific aortic valve stenosis. Numerous studies have been performed in adults about the pathophysiology and epidemiology of Lp(a) and research is under way for the development of drugs capable of reducing Lp(a) plasma values. Much less information is available regarding Lp(a) in children and adolescents. The present article reviews the evidence on this topic. The review addresses the issues of Lp(a) changes during growth, the correlation between Lp(a) values in children and those in their parents, and between Lp(a) levels in children, and the presence of cardiovascular disease in the family. Gaining information on these points is particularly important for deciding whether Lp(a) assay may be useful for defining the cardiovascular risk in children, in order to plan a prevention program early.

Background It is not known whether, in children and adolescents with alterations in weight and/or blood pressure (BP), lifestyle modifications are associated with an improvement of early cardiac damage.Methods In a pediatric population referred for excess weight, high BP, or both (n = 278, 10.6 (2.3) years), echocardiography was performed at enrollment and after 15 months of follow-up, during which participants received nonpharmacological treatment, based on correcting unhealthy lifestyles and improving dietary habits. Left ventricular mass was indexed for height (g/m(2.7), LVMI), and an LVMI value higher than or equal to age- and gender-specific 95(th) percentile was the criterion for defining left ventricular hypertrophy (LVH). Multiple linear and logistic regression analyses were carried out to determine associations between changes in BMI and BP z-scores and changes of LVMI values and LVH prevalence, from baseline to follow-up.Results At baseline, 33.1% of study participants were hypertensive, 52.9% obese, and 36.3% had LVH. At follow-up, the prevalence of hypertension, obesity, and LVH was 18.7%, 30.2%, and 22.3%, respectively (p < 0.001 for all). A decrease in LVMI from 37.1 to 35.2 g/m(2.7) (p < 0.001) was observed. Only delta BMI z-score positively related to an improvement of LVMI. Reductions of BMI (OR = 0.22, 95% CI 0.07-0.64) and diastolic BP (OR = 0.64, 95% CI 0.42-0.93) z-scores from baseline to follow-up and family history of hypertension (OR = 0.36, 95% CI 0.16-0.78) were associated with a lower prevalence of LVH.Conclusions In a pediatric population at cardiovascular risk, changing incorrect lifestyle and dietary habits is associated with both reduction of BMI and BP values and regression of early cardiac damage.

High blood pressure (BP) and excess weight can lead to early cardiovascular organ damage already in children. Carotid-femoral pulse wave velocity (cf-PWV) is the non-invasive gold standard method for assessing aortic stiffness, while carotid-radial PWV (cr-PWV) provides information on the distensibility of the upper limb arteries. The aim of this study was to evaluate the relationship of BP and BMI z-scores with arterial stiffness and left ventricular mass index (LVMI) in a pediatric population.

OBJECTIVE AND METHODS: The study aimed at evaluating, in a large sample of Italian children, the reclassification of blood pressure categories with the new U.S. nomograms, obtained in a population of normal-weight children (American Academy of Pediatrics Clinical Practice Guidelines, AAP-CPG), compared with the Fourth Report/European Society of Hypertension (ESH) nomograms. The performance of the two classifications in identifying the presence of left ventricular hypertrophy was also assessed. RESULTS: In 951 individuals referred to a Pediatric Center for Cardiovascular Risk Prevention, a 12% increase in the prevalence of children with blood pressure at least 90th percentile was observed by using the new nomograms. In the subsample of children aged at least 13 years, the application of the blood pressure fixed cutoff values of 120/<80 mmHg (for 'elevated' blood pressure) and of 130/80 mmHg (for hypertension) led to a change in the blood pressure category (worse or better) in about 30% of cases as compared with the AAP-CPG classification based on percentiles. Regarding the identification of individuals with left ventricular hypertrophy, the AAP-CPG classification led to an increase in the true positive fraction (sensitivity) of 5.5%, and to an increment of the false-positive fraction (1 - specificity) of 5.8%. The logistic regression model, adjusted for possible confounding factors, and the ROC curves obtained from the linear predictor of the model showed an identical performance of the Fourth Report/ESH and the AAP-CPG classifications. CONCLUSION: In our paediatric population, the AAP-CPG classification slightly increased the prevalence of elevated blood pressure values compared with the Fourth Report/ESH classification. Moreover, the application of more 'physiological' nomograms, based on a population of normal-weight children, did not yield any advantage in identifying individuals with early cardiac organ damage

The aim of this study was to investigate the relationship between endothelin-1, nitric oxide, insulin resistance, and blood pressure in young subjects with a high prevalence of excess weight and/or elevated blood pressure. In a cohort of 238 children (mean age = 11.1 years), height, weight, waist circumference, and blood pressure were assessed. Body mass index, waist-to-height ratio, and blood pressure percentiles were calculated, and the children were classified as having excess weight and elevated blood pressure according to the International Obesity Task Force and the US blood pressure nomograms specific for gender, age and height, respectively. Endothelin-1 and nitric oxide production were assessed, and the homeostatic model assessment index was calculated. Forty-three percent of children were male, 71% had excess weight, and 37% had systolic and/or diastolic values above the ninetieth percentile. Plasma endothelin-1 and nitric oxide production were independently correlated (p < 0.05). In multivariate analyses, the HOMA index was associated with systolic and diastolic blood pressure (p = 0.01), and nitric oxide was independently related to diastolic blood pressure (p = 0.04), even after adjustment for measures of body composition. By using the waist-to-height ratio instead of BMI in the statistical model, the association between the homeostatic model assessment index and blood pressure was attenuated, while the results remained similar for nitric oxide. No correlation was found between endothelin-1 and blood pressure. In our study population, the correlation between nitric oxide and blood pressure and the lack of a relationship between endothelin-1 and blood pressure could be explained by an increase in the vasodilator effect of local and systemic nitric oxide, which counteracts the possible hypertensive effect of endothelin-1.

BACKGROUND Children's excess weight is a common problem due to low-quality diet and poor physical activity and is a risk factor associated with hypertension. Aim of this study was to assess the effect of a nonpharmacological multidisciplinary intervention on blood pressure (BP) and body weight in a population of children with excess weight and/or elevated BP. METHODS Children consecutively referred to a Prevention of Cardiovascular Risk Clinic by the primary care pediatrician from 2009 to 2015 were assessed at baseline and followed up over time. RESULTS Out of 273 children (median age 11.4 years, 55% male), 61% were excess weight only, 7% had elevated BP only, and 32% showed both conditions. The probability of reaching the clinical target (normal weight and BP values) at 1 year of follow-up was 19% (confidence interval [CI]: 14%; 24%) and increased up to 38% (CI: 28%; 47%) at 3 years. At 1 year of follow-up, in the overall population both body mass index (BMI) and systolic BP z-scores decreased significantly from 1.77 to 1.47 and from 0.99 to 0.52, respectively (P < 0.0001). BP was significantly reduced in both children with elevated BP only (reduction = 0.91, P = 0.0157) and subjects with excess weight and elevated BP (reduction = 0.89, P < 0.0001). Variables significantly related with systolic BP z-score at 1 year of follow-up were baseline systolic BP z-score and BMI z-score reduction during follow-up (P < 0.001 and P = 0.0003, respectively). CONCLUSION Our data demonstrate the efficacy of lifestyles modification on weight and BP in children, both when elevated BP and excess weight were present as distinct clinical problems and in the case of their association.

The present article intends to provide an update of the article "Focus on prevention, diagnosis and treatment of hypertension in children and adolescents" published in 2013 (Spagnolo et al., Ital J Pediatr 39:20, 2013) in this journal. This revision is justified by the fact that during the last years there have been several new scientific contributions to the problem of hypertension in pediatric age and during adolescence. Nevertheless, for what regards some aspects of the previous article, the newly acquired information did not require substantial changes to what was already published, both from a cultural and from a clinical point of view. We felt, however, the necessity to rewrite and/or to extend other parts in the light of the most recent scientific publications. More specifically, we updated and extended the chapters on the diagnosis and management of hypertension in newborns and unweaned babies, on the use and interpretation of ambulatory blood pressure monitoring, and on the usefulness of and indications for physical activity. Furthermore, we added an entirely new section on the role that simple carbohydrates (fructose in particular) and uric acid may play in the pathogenesis of hypertension in pediatric age.