Markers of atherosclerotic development in children with familial hypercholesterolemia: a literature review

Atherosclerosis. 2014 Aug;235(2):299-309. doi: 10.1016/j.atherosclerosis.2014.05.917. Epub 2014 May 20.


Objective: Atherosclerosis is a multi-step process, where lipids, inflammatory and hemostatic mediators orchestrate plaque formation and progression, which subsequently may lead to myocardial infarction and ischemic stroke. Familial hypercholesterolemia (FH) is associated with increased risk of premature atherosclerosis due to the genetically determined elevated low density lipoprotein (LDL)-cholesterol seen in these individuals. Children with FH are suitable to investigate the isolated effect of elevated LDL-cholesterol on early markers of atherosclerosis. The aim of the present paper was to review the literature to summarize the findings of atherosclerotic markers in children with FH to better understand how elevated LDL-cholesterol per se promotes atherogenesis.

Methods: We conducted a systematic literature search from the years 1990-2013, resulting in identification of 903 articles. In order to investigate whether intima-media thickness (IMT) is different in children with and without FH, we conducted a meta-analysis of the studies comparing FH children with a control group.

Results: 37 original articles were included. Among these, 24 reported subclinical measurements, whereas other articles reported measurements of atherogenic lipids (n = 9), inflammatory markers (n = 10), hemostatic markers (n = 6) and other surrogate markers of atherosclerosis (n = 7). In the meta-analysis (n = 8), IMT was significantly thicker in children with FH than in control children (weighted mean difference 0.06, 95% confidence interval [0.01, 0.11]).

Conclusion: Elevated LDL-cholesterol distinguishes children with and without FH, but these groups of children also differ in several other ways. In particular, children with FH display a variety of changes reflecting both the lipid and the inflammatory arm of atherosclerosis. The IMT-meta-analysis result strengthens the evidence of early atherosclerotic development in children with FH. In a clinical perspective, early diagnosing and treatment of children with FH is of high importance to attenuate development of the potential ongoing early atherosclerotic process in these individuals.

Keywords: Atherosclerosis; Children; Familial hypercholesterolemia; Literature review; Markers of atherosclerosis.

Publication types

  • Meta-Analysis
  • Research Support, Non-U.S. Gov't
  • Review

MeSH terms

  • Adolescent
  • Atherosclerosis / etiology*
  • C-Reactive Protein / metabolism
  • Carotid Intima-Media Thickness
  • Child
  • Child, Preschool
  • Cholesterol, LDL / blood
  • Endothelium, Vascular / physiopathology
  • Humans
  • Hyperemia / complications
  • Hyperlipoproteinemia Type II / complications*
  • Infant
  • Infant, Newborn
  • Leukocytes, Mononuclear / metabolism
  • Lipoprotein(a) / blood
  • Lipoproteins, LDL / blood
  • Regional Blood Flow
  • Vasodilation


  • Cholesterol, LDL
  • Lipoprotein(a)
  • Lipoproteins, LDL
  • oxidized low density lipoprotein
  • C-Reactive Protein