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Circulation. 2019;139:e1082–e1143. DOI: 10.1161/CIR.0000000000000625 June 18/25, 2019 e1111 CLINICAL STATEMENTS AND GUIDELINES

for Cardiovascular Health and Risk Reduction in Children and Adolescents,S4.4.4.3-41 universal pediatric lipid screening has been advised in recent pediatric guidelines,S4.4.4.3-42 specifically focusing on ages 9 to 11 years and then ages 17 to 21 years because TC and LDL-C levels decrease 10% to 20% during puberty. However, the long-term benefits and harms of universal screening have not been tested in RCTs. Observational studies demonstrate that universal screening can identify severe lipid abnormalities,S4.4.4.3-18,S4.4.4.3-19 and in scant data universal screening is associated with changes in family lifestyle behaviors. Nonfasting lipid parameters are similar to fasting ones, and screening with a nonfasting non–HDL-C is a reasonable approach to population screening in childhood. Although research on this topic continues, universal screening may be reasonable given the substantial benefits of identifying severe hypercholesterolemia (see Section 4.2., “Severe Hypercholesterolemia”), including FH, and possible benefits of lifestyle counseling for multifactorial dyslipidemias.S4.4.4.3-3, S4.4.4.3-5–S4.4.4.3-9,S4.4.4.3-25,S4.4.4.3-26,S4.4.4.3-38–S4.4.4.3-40 4.5 Other Populations at Risk

4.5.1 Ethnicity

Recommendation for Other Populations at Risk Referenced studies that support the recommendation are summarized in Online Data Supplements 24 to 30.

COR LOE Recommendation

IIa B-NR 1.  For clinical decision-making in adults of different race/ethnicities, it is reasonable for clinicians to review race/ethnic features that can influence ASCVD risk.S4.5.1-1 so as to adjust choice of statin or intensity of treatmentS4.5.1-1–S4.5.1-4

Synopsis

Race/ethnicity factors can influence estimations of AS- CVD risk,S4.5.1–S4.5.1-4 intensity of treatmentS4.5.1-1–S4.5.1-4 or even lipid drug use.S4.5.1-5,S4.5.1-6 Important examples include the heightened risk of ASCVD in those who identify as South Asians, the increased sensitivity to statins in those who identify as East Asians, and the increased prevalence of hypertension in blacks. An important issue in management of ASCVD risk in those who identify as Hispanics/Latinos in the United States is the lack

Table 10.  Racial/Ethnic Issues in Evaluation, Risk Decisions, and Treatment of ASCVD Risk

Racial/Ethnic Groupings

Asian AmericansS4.5.1-4, S4.5.1-13* Hispanic/Latino AmericansS4.5.1-7–S4.5.1-11† Blacks/African AmericansS4.5.1-14 Comments

Evaluation ASCVD issues informed by

race/ethnicity ASCVD issues informed by race/ ethnicity ASCVD risk in people of South Asian and East Asian origin varies by country of origin; individuals from South Asia (see below) have increased ASCVD risk. Race/ethnicity and country of origin, together with socioeconomic status and acculturation level, may explain risk factor burden more precisely (eg, ASCVD risk is higher among individuals from Puerto Rico than those from Mexico). ASCVD risk assessment in black women shows increased ASCVD risk compared with their otherwise similar white counterparts There is heterogeneity in risk according to racial/ethnic group and within racial/ethnic groups. Native American/ Alaskan populations have high rates of risk factors for ASCVD compared with non-Hispanic whites.S4.5.1-12 Lipid issues informed by

race/ethnicityS4.5.1-15,S4.5.1-16 Asian Americans have lower levels of HDL-C than whites. Hispanic/Latino women have higher prevalence of low HDL-C compared to Hispanic/ Latino men. Blacks have higher levels of HDL-C and lower levels of triglycerides than non-Hispanic whites or Mexican Americans. All ethnic groups appear to be at greater risk for dyslipidemia, but important to identify those with more sedentary behavior and less favorable diet.

There is higher prevalence of LDL-C among Asian Indians, Filipinos, Japanese, and Vietnamese than among whites. An increased prevalence of high TG was seen in all Asian American subgroups.

Metabolic issues

informed by race/ ethnicityS4.5.1-3, S4.5.1-17, S4.5.1-18 Increased MetS is seen with lower waist circumference than in whites. DM is disproportionately present compared with whites and blacks. There is increased prevalence of MetS and DM in Mexican Americans compared with whites and Puerto Ricans. There is increased DM and hypertension. There is increased prevalence of DM. Features of MetS vary by race/ethnicity. Waist circumference, not weight, should be used to determine abdominal adiposity when possible.

DM develops at a lower lean body mass and at earlier ages.S4.5.1-19–S4.5.1-21 Majority of risk in South Asians is explained by known risk factors, especially those related to insulin resistance.S4.5.1-13

Risk Decisions PCES4.5.1-22–S4.5.1-25 No separate PCE is available; use PCE for whites. PCE may underestimate ASCVD risk in South Asians. PCE may overestimate risk in East Asians.S4.5.1-26 No separate PCE is available; use PCE for non-Hispanic whites. If African-American ancestry is also present, then use PCE for blacks. Use PCE for blacks.S4.5.1-10 Country-specific race/ ethnicity, along with socioeconomic status, may affect estimation of risk by PCE.

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