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Familial hypercholesterolemia in childhood and adolescents: A hidden reality
Hipercolesterolemia familiar en la infancia y la adolescencia: una realidad oculta
Núria Plana
Corresponding author
nplana@grupsagessa.cat

Corresponding author.
, Cèlia Rodríguez-Borjabad, Daiana Ibarretxe, Lluís Masana
Unitat de Medicina Vascular i Metabolisme, Hospital Universitari Sant Joan de Reus, Unitat d’Investigació en Lípids i Arteriosclerosi, Universitat Rovira i Virgili, Institut d’Investigació Sanitària Pere Virgili (IISPV), Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas (CIBERDEM), Reus, Tarragona, Spain
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">LDL cholesterol reduction according to the treatment administered to children with homozygous familial hypercholesterolaemia&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">27</span></a></p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Familial hypercholesterolaemia &#40;FH&#41; is a genetic autosomal dominant disorder&#44; which means that there is a 50&#37; chance of parent-to-child transmission&#46; It is primarily caused by mutations in the gene that encodes the low-density lipoprotein receptor&#46; At present&#44; over 1700 different gene mutations have been described&#44; representing over 90&#37; of all FH cases&#46; To a lesser extent&#44; defects in the gene encoding Apolipoprotein B &#40;ApoB&#41; and the gene encoding <span class="elsevierStyleItalic">proprotein convertase subtilisin&#47;kexin type 9</span> &#40;PCSK9&#41; have been described&#44; representing approximately 5&#37; and 1&#37; of cases&#44; respectively&#46; Clinically&#44; these are expressed in the same way and only genetic testing can help us tell them apart&#46; Nevertheless&#44; in around 5&#8211;30&#37; of current cases with the FH phenotype&#44; it is not possible to identify the gene responsible for this disease&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">There are two types of FH&#58; heterozygous &#40;HeFH&#41;&#44; which is the most common hereditary disorder with a prevalence of 1&#47;250&#8211;500 individuals&#44; and homozygous &#40;HoFH&#41;&#44; with a prevalence of 1&#47;160&#44;000&#8211;300&#44;000 individuals&#44; according to the most recent data published on the European population&#46;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">2&#44;3</span></a> Zamora et al&#46; analysed the electronic records of 2&#44;764&#44;917 patients in Catalonia using the Big Data methodology&#46; Using the cut-off level of low-density lipoprotein cholesterol &#40;LDL-C&#41;&#44; described previously in the Spanish population&#44; 14&#44;274 were found to have a FH-compatible phenotype&#46; These data indicate a HeFH prevalence of 1&#47;256 subjects in the Spanish population&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">4</span></a> S&#225;nchez reported a HoFH prevalence of 1&#47;495&#44;000 subjects after analysing 16&#44;744 genetic studies performed in Spain between 1996 and 2015&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In Europe&#44; it is estimated that the number of affected patients is around 4&#46;5 million&#44; of which 20&#8211;25&#37; are children and adolescents&#46; The fact that less than 10&#37; are diagnosed is a problem of huge clinical significance&#46; In countries with intensive genetic screening programmes&#44; like the Netherlands&#44; percentages of detection exceed 70&#37;&#46; In Spain&#44; the rate of FH patients who have undergone testing and been diagnosed is around 6&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">6</span></a> Individuals with FH are 100 times more likely to develop premature cardiovascular disease &#40;PCVD&#41; than unaffected individuals&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">7</span></a> It is estimated that 85&#37; of men and 50&#37; of women will present with some form of coronary event before the age of 65 if they do not receive adequate treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">8</span></a> Children with HoFH have an increased risk of developing coronary heart disease before 20 years of age if they do not receive intensive treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">2&#44;9</span></a> As such&#44; early diagnosis and treatment are important for prognosis and long-term outcome&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Patients affected by FH present high plasma concentrations of LDL-C&#44; which may be detected from birth&#46; Children with HeFH have LDL-C levels that are three-times higher than unaffected individuals<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">10</span></a> and the condition may manifest as premature coronary heart disease in adulthood&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In spite of all this&#44; there is no clinical expression in childhood&#44; thus necessitating the design and application of different strategies for its detection&#46; The clinical criteria of the <span class="elsevierStyleItalic">Dutch Lipid Clinic Network</span> are not applicable to patients under the age of 18&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">11</span></a> In children&#44; diagnostic suspicion should be established based on high LDL-C levels&#44; family history of hypercholesterolaemia and&#47;or PCVD&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The ideal age for detection is currently considered to be around 8&#8211;10 years&#44; as this is the age of maximum discrimination&#46; During adolescence&#44; total cholesterol &#40;TC&#41; and LDL-C values decrease by around 10&#8211;20&#37;&#44; thus making this stage of life less sensitive for the performance of screening&#46;<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">12&#44;13</span></a> Recently&#44; Eissa et al&#46; reported that lipid profiles vary considerably depending on the stage of pubertal development&#46; They propose that this should be considered when screening is indicated&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">14</span></a> Pang et al&#46; studied 1602 healthy adolescents between the ages of 14 and 17&#44; defining FH according to LDL-C levels and family history of hypercholesterolaemia and&#47;or PCVD&#46; The prevalence of FH was 1&#47;267 adolescents&#44; with the authors underlining the absence of PCVD in parents&#44; but the presence of PCVD in grandparents&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">15</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Various studies have been published in which it has been observed that carotid artery intima-media thickness is higher in children with the FH phenotype than in normolipaemic children&#44; as it is directly related to LDL-C levels&#46; This significant difference in carotid artery intima-media thickness was observed in children from 7 years of age&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">2</span></a> The presence of coronary calcifications has also been observed in 25&#37; of HeFH patients aged 11&#8211;23 years&#44; and especially in the aortic artery of the majority of adolescents with HoFH&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Detecting FH in the paediatric population is still a major challenge&#44; as the vast majority are undiagnosed&#44; thus leading to a delay in the onset of treatment&#44; both in terms of lifestyle changes and drugs&#44; which may cause coronary risk to increase in this population during middle age&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The LDL-C cut-off level&#44; the age at screening or the criteria for suspecting the condition in a parent are currently a source of dispute&#59; this review thus describes different screening strategies for improving detection and diagnosis in children with FH&#46; In turn&#44; this review includes up-to-date recommendations on lifestyle changes and pharmacological treatment&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Children and adolescents with familial hypercholesterolaemia</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Why perform screening&#63;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Screening in childhood and adolescence is completely justified&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0055" class="elsevierStylePara elsevierViewall">Hypercholesterolaemia increases the risk of accelerated arteriosclerosis development and&#44; as a result&#44; PCVD&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0060" class="elsevierStylePara elsevierViewall">Screening may help to identify this high-risk population&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0065" class="elsevierStylePara elsevierViewall">At present&#44; safe and effective pharmacological treatments are available that may slow down or even reverse arteriosclerosis&#44; thereby decreasing cardiovascular &#40;CV&#41; risk in these children&#46;</p></li></ul></p><p id="par0070" class="elsevierStylePara elsevierViewall">However&#44; despite the evidence&#44; there is currently no consensus&#46; If we compare the strategies recommended on different continents&#44; we can observe differences between them&#46; Moreover&#44; there are even discrepancies between the countries within Europe&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">7</span></a></p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Types of screening strategies</span><p id="par0075" class="elsevierStylePara elsevierViewall">There are different strategies&#8212;which are not mutually exclusive&#8212;for diagnosing new cases among the paediatric population&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Universal screening</span>&#58; consists of the routine measurement of TC levels in children of a certain age&#46; This method has been proven to detect 90&#37; of children with FH between the ages of 1&#8211;9&#44; with a false positive ratio of less than1&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">16</span></a> An example of this type of screening is the model applied in Slovenia at 5 years of age&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">17</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Failing that&#44; opportunistic screening is recommended&#44; i&#46;e&#46; the inclusion of the TC assessment in any blood test prescribed by the paediatrician between 2 and 9 years of age&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Selective screening</span>&#58; consists of the measurement of TC levels in children with a family history of either PCVD or hypercholesterolaemia in one of the parents&#46; This type of screening was recommended by the first paediatric expert panel&#44; the <span class="elsevierStyleItalic">National Cholesterol Education Program</span>&#44;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">17</span></a> by the <span class="elsevierStyleItalic">American Heart Association</span><a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">18</span></a> and the <span class="elsevierStyleItalic">American Academy of Pediatrics</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">19</span></a> However&#44; it has become apparent that&#44; on applying this screening method&#44; between 30&#37; and 60&#37; of children with FH pass by undetected&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Direct cascade screening</span>&#58; if we know the genetic mutation responsible for the parent&#39;s FH&#44; genetic testing is extended to all first-degree relatives&#44; including children&#46; This type of genetic screening boasts 100&#37; sensitivity and specificity in family studies and is recommended as it is the technique that offers the best cost-effectiveness&#46; A clear example of this type of screening is the model applied in the Netherlands from 1994 to the end of 2014&#46;<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">20&#44;21</span></a> In the United Kingdom&#44; guidelines recommend performing genetic testing in adult individuals and extending cascade screening to children over 10 years of age&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">7</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">In Spain&#44; the SAFEHEART study detected a total of 1984 new relatives with FH from 768 probands&#46; The authors highlight that&#44; despite being a hereditary disorder&#44; 25&#37; of the detected relatives did not know that they were carriers of the disease and 20&#37; did not receive treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">22</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Data from the study by Oliva et al&#46; suggest that familial cascade screening with genetic testing and subsequent statin treatment is cost-effective&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">23</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Reverse cascade screening</span>&#58; where testing is initiated in the parents after detecting hypercholesterolaemia in the child&#46; If one parent presents a score<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>6 in the clinical criteria of the <span class="elsevierStyleItalic">Dutch Lipid Clinic Network</span>&#44; genetic testing will be requested&#46; If the mutation is detected&#44; genetic testing will be performed on the child&#46; In contrast&#44; if the result is negative&#44; the child will not undergo testing&#44; but he&#47;she may be diagnosed with FH if LDL-C levels exceed the 95th percentile&#46; Various guidelines recommend performing this type of screening&#44; but it is underused in clinical practice&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> depicts the up-to-date guidelines and the types of screening they recommend&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Screening strategies in Spain</span><p id="par0115" class="elsevierStylePara elsevierViewall">Various FH reviews and consensuses have been published in recent years&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">Asociaci&#243;n Espa&#241;ola de Pediatr&#237;a</span> &#91;Spanish Association of Paediatrics&#93; published guidelines for treating children with hypercholesterolaemia<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">24</span></a> that can be summarised as follows&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0125" class="elsevierStylePara elsevierViewall">Universal screening is not recommended&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0130" class="elsevierStylePara elsevierViewall">Selective screening is recommended if there is a history of PCVD in first- and second-degree relatives and&#47;or a TC value &#62;240<span class="elsevierStyleHsp" style=""></span>mg&#47;dL in one parent&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0135" class="elsevierStylePara elsevierViewall">The ideal screening age is between 2 and 10 years&#46;</p></li></ul></p><p id="par0140" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">Sociedad Espa&#241;ola de Arteriosclerosis</span> &#91;Spanish Arteriosclerosis Society&#93; published an expert consensus document<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">11</span></a>&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0145" class="elsevierStylePara elsevierViewall">Universal screening in all children between 8 and 10 years of age&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">-</span><p id="par0150" class="elsevierStylePara elsevierViewall">Direct cascade screening of first-degree relatives of patients with a genetic diagnosis of FH&#44; irrespective of TC levels&#46; If the genetic test comes back negative&#44; LDL-C levels should be determined in all first-degree relatives&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">-</span><p id="par0155" class="elsevierStylePara elsevierViewall">Reverse cascade screening of first-degree relatives of children with LDL-C levels &#62;135<span class="elsevierStyleHsp" style=""></span>mg&#47;dL or established genetic testing&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">-</span><p id="par0160" class="elsevierStylePara elsevierViewall">Selective screening of children with a family history of PCVD and&#47;or hypercholesterolaemia&#46;</p></li></ul></p><p id="par0165" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">Fundaci&#243;n de Hipercolesterolemia Familiar</span> &#91;Familial Hypercholesterolaemia Foundation&#93; published an expert consensus document<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">25</span></a>&#58;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">-</span><p id="par0170" class="elsevierStylePara elsevierViewall">Direct cascade screening from 2 years of age when one of the parents is diagnosed and&#44; if possible&#44; before 8 years of age&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">-</span><p id="par0175" class="elsevierStylePara elsevierViewall">Suspect FH in children with LDL-C levels<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>190<span class="elsevierStyleHsp" style=""></span>mg&#47;dL or LDL-C<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>150<span class="elsevierStyleHsp" style=""></span>mg&#47;dL where there is a family history of PCVD and&#47;or hypercholesterolaemia in one of the parents and&#47;or a genetic confirmation in one of them&#46;</p></li></ul></p></span></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Suspicion and diagnosis</span><p id="par0180" class="elsevierStylePara elsevierViewall">The clinical diagnosis of FH in childhood can be difficult as a phenotypic overlap with polygenic hypercholesterolaemia can sometimes be observed&#46; The child&#39;s diagnosis should preferably be genetic&#59; however&#44; this is not always possible&#46; In this case&#44; we will rely on the child&#39;s phenotypic expression and any family history of PCVD and&#47;or hypercholesterolaemia indicating FH&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">At present&#44; in our field clinical suspicion will be based on family histories and TC levels&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the lipid profile considered to be within the normal and pathological range according to age&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0190" class="elsevierStylePara elsevierViewall">In light of TC levels<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>200<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#44; a second test is recommended within a maximum period of 3 months&#44; requesting a full lipid profile&#46; It would be advisable to also use the second blood draw to rule out secondary causes of hypercholesterolaemia in childhood &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; If TC values<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>200<span class="elsevierStyleHsp" style=""></span>mg&#47;dL and LDL-C levels<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>130<span class="elsevierStyleHsp" style=""></span>mg&#47;dL are confirmed and secondary causes have been ruled out&#44; we should recommend a period of dieting for no less than 6 months&#46; After this period&#44; if LDL-C levels<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>130<span class="elsevierStyleHsp" style=""></span>mg&#47;dL persist in an additional test&#44; we should suspect FH if accompanied by another condition &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46; If the child&#39;s test is the result of selective screening&#44; his&#47;her full lipid profile will be requested immediately&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0195" class="elsevierStylePara elsevierViewall">If LDL-C levels are &#8805;190<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#44; obtained over 2 consecutive tests with a 3-month gap&#44; the probability of finding a causative mutation for FH is very high&#46; If LDL-C levels are &#8805;160<span class="elsevierStyleHsp" style=""></span>mg&#47;dL after a period of dieting and there is a history of PCVD in first-degree relatives &#40;men<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>55 years&#44; women<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>60 years&#41; or second-degree relatives &#40;men<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>45 years&#44; women<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>50 years&#41; and&#47;or hypercholesterolaemia &#40;c-LDL<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>190<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41; or one of the parents is receiving a lipid-lowering pharmacological treatment&#44; there is a high probability of them being a carrier of a causative mutation for FH&#46; If the causative mutation has been detected in one of the parents and the child has LDL-C levels<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>130<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#44; he&#47;she is also very likely to carry this mutation&#46; If the parent has died due to PCVD and the child presents with LDL-C levels<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>130<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#44; genetic testing should be attempted&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Genetic testing is recommended&#46; However&#44; at present this is not possible in the entire Spanish population and there are large differences between autonomous communities&#44; with very different circumstances and realities&#46; A clear example of this is that&#44; while in the Canary Islands and Murcia&#44; genetic testing is not subsidised&#44; in Castile and Le&#243;n&#44; there is no form of restriction&#46;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">26</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">LDL-C levels in children with HeFH range between 190 and 500<span class="elsevierStyleHsp" style=""></span>mg&#47;dL while&#44; in those with HoFH&#44; this figure ranges between 500 and 1000<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#44; together with the presence of tuberous xanthomas and arcus senilis before the age of 10&#46; However&#44; an overlap of LDL-C levels of between 300 and 500<span class="elsevierStyleHsp" style=""></span>mg&#47;dL can be seen in both forms&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">27</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">Recently&#44; a computer program has been designed that calculates the probability of detecting a mutation in a patient with suspected FH and which aims to increase detection in young people&#46; This tool is based on the data collected over a 20-year period in the Dutch FH detection programme &#40;<a href="http://vasculaironderzoekamc.nl/fh-calculator/">http&#58;&#47;&#47;vasculaironderzoekamc&#46;nl&#47;fh-calculator&#47;</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">28</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Therapeutic objectives</span><p id="par0215" class="elsevierStylePara elsevierViewall">There is no evidence that indicates therapeutic objectives in children with FH&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> summarises the different therapeutic objectives in relation to the various guidelines published in recent years&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Therapeutic recommendations</span><p id="par0220" class="elsevierStylePara elsevierViewall">It is important to initiate therapy early in children with FH&#46;<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">29</span></a></p><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Lifestyle changes</span><p id="par0225" class="elsevierStylePara elsevierViewall">A balanced and healthy diet is key to FH treatment and in order to prevent arteriosclerosis&#46; It has been observed that diet may reduce LDL-C levels by 10&#8211;15&#37;&#44; although this can vary significantly according to the type of patient and type of mutation&#46;<a class="elsevierStyleCrossRefs" href="#bib0420"><span class="elsevierStyleSup">24&#44;25</span></a> It is worth noting that&#44; in these children&#44; dietetic recommendations alone are not going to be sufficient to achieve the therapeutic objectives&#59; nonetheless&#44; maintaining an appropriate weight remains important in order to avoid adding further CV risk factors&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">30</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">These recommendations should be indicated from 2 years of age under the supervision of a qualified dietician&#47;nutritionist who helps to reinforce nutrition therapy in the family setting in order to achieve better treatment adherence&#46;<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">31</span></a></p><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Fat</span><p id="par0245" class="elsevierStylePara elsevierViewall">Fat consumption should be limited to &#60;30&#37; of the total calorie intake&#46; Until recently&#44; many of the guidelines published specified the need to lower all types of fat and to place special emphasis on the importance of limiting cholesterol intake &#40;&#60;200&#8211;300<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41;&#46; However&#44; more stress is now being placed on quality over quantity&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">The intake of saturated fatty acids should be &#60;10&#37;&#59; however&#44; some guidelines are stricter and state it is best to stay below 7&#37;&#46; Reducing saturated fat and cholesterol in children&#39;s diets has not been shown to alter their nutritional status&#44; growth or pubertal development&#46;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">32</span></a> Their monounsaturated fat intake should be kept at around 10&#37;&#44; principally in the form of oleic acid&#46; The <span class="elsevierStyleItalic">trans</span> fats found in processed foods should be avoided&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">Different clinical trials have shown that the daily consumption of plant stanols and sterols at doses of 1&#46;5&#8211;3<span class="elsevierStyleHsp" style=""></span>g&#47;day in children and adolescents with HeFH can be beneficial in reducing LDL-C levels by approximately 9&#8211;19&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">33</span></a> Recently&#44; the European Atherosclerosis Society published a consensus panel which recommends consumption of plant stanols and sterols in FH patients from 6 years of age&#44; as long as their fruit and vegetable intake is sufficient in order to avoid a fat-soluble vitamin deficiency&#46;<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">34</span></a></p><p id="par0260" class="elsevierStylePara elsevierViewall">None of the following types of supplement is recommended&#58; linoleic acid&#44; omega 3&#44; rapeseed oil&#44;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">35</span></a> soy protein&#44; garlic extracts<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">36</span></a> or cereals containing psyllium extract&#46;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">37</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Carbohydrates</span><p id="par0265" class="elsevierStylePara elsevierViewall">Carbohydrates include fibres&#44; starches and sugars&#46; They can also be categorised into two types&#58; simple and complex&#46; Complex carbohydrates should be promoted as they have a lower percentage of calories and a high fibre content &#40;whole grains&#44; pasta&#44; rice&#44; bread&#44; potatoes&#44; legumes&#44; fruit and vegetables&#41;&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">The latest European guidelines on cardiovascular disease prevention advise a fibre intake of 30&#8211;45<span class="elsevierStyleHsp" style=""></span>g&#47;day&#46; The consumption of water-soluble fibre in the form of fortified cereals can be added to diets that are low in fat or saturated fat&#44; and the recommended daily dose is 6<span class="elsevierStyleHsp" style=""></span>g&#47;day for children aged 2&#8211;12 and 12<span class="elsevierStyleHsp" style=""></span>g&#47;day for those over 12&#46;</p><p id="par0275" class="elsevierStylePara elsevierViewall">The intake of simple sugars should also be reduced&#44; along with the sugar content in soft drinks&#46;<a class="elsevierStyleCrossRefs" href="#bib0490"><span class="elsevierStyleSup">38&#44;39</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Proteins</span><p id="par0280" class="elsevierStylePara elsevierViewall">A protein intake of around 15&#37; should be advised&#46; Preference should be given to the consumption of white meat and fish&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Salt</span><p id="par0285" class="elsevierStylePara elsevierViewall">Many of the clinical guidelines recommend a maximum intake of 5<span class="elsevierStyleHsp" style=""></span>g&#47;day &#40;2<span class="elsevierStyleHsp" style=""></span>g of sodium&#41;&#46; In children under 10 years of age&#44; less than 3&#8211;4<span class="elsevierStyleHsp" style=""></span>g&#47;day is advisable&#59; however&#44; the average consumption among this age group is 8&#46;1<span class="elsevierStyleHsp" style=""></span>g&#47;day&#46;<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">40</span></a> Around 75&#37; comes from processed foods&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Alcohol</span><p id="par0290" class="elsevierStylePara elsevierViewall">Among the school population aged between 14 and 18 years&#44; the most widely consumed drink during the week is beer&#59; at the weekends&#44; spirits and mixers are most common&#46;</p><p id="par0295" class="elsevierStylePara elsevierViewall">It is important to teach children not to consume alcohol&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Physical exercise</span><p id="par0300" class="elsevierStylePara elsevierViewall">Maintaining an ideal weight and encouraging physical exercise are key factors among the set of measures to be followed&#46;</p><p id="par0305" class="elsevierStylePara elsevierViewall">Ideally&#44; children should exercise for over an hour every day&#44; and should spend less than 2<span class="elsevierStyleHsp" style=""></span>h performing sedentary activities such as playing on consoles or computers and&#47;or watching TV&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">4</span></a></p><p id="par0310" class="elsevierStylePara elsevierViewall">It has been observed that physical exercise patterns established during childhood remain lifelong habits and are associated with increased high-density lipoprotein cholesterol and reduced LDL-C&#46;<a class="elsevierStyleCrossRefs" href="#bib0505"><span class="elsevierStyleSup">41&#44;42</span></a></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Smoking</span><p id="par0315" class="elsevierStylePara elsevierViewall">The European CV prevention guidelines propose different strategies for promoting smoking cessation&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">13</span></a> Tobacco consumption has decreased by 60&#37; in the last decade according to the report issued by the Spanish Ministry of Health&#59; nevertheless&#44; 38&#46;4&#37; of Spanish teenagers admit to having smoked at least once and 8&#46;9&#37; do so on a daily basis&#46;</p><p id="par0320" class="elsevierStylePara elsevierViewall">Smoking is another CV risk factor and this risk is even higher in patients with FH&#46;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">43</span></a></p></span></span></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Pharmacological treatment</span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Efficacy and tolerance of statins</span><p id="par0325" class="elsevierStylePara elsevierViewall">Statins are the drugs of choice in the pharmacological management of children with FH&#46; They will always be preceded by a period of dietary treatment&#46; Pharmacological treatment should start before puberty as this improves control and parental adherence&#44; with the child&#39;s acceptance also being greater&#46;</p><p id="par0330" class="elsevierStylePara elsevierViewall">Statins act by competitively inhibiting the 3-HMG-CoA reductase enzyme&#44; leading to a decrease in intrahepatic cholesterol synthesis and an increase in LDL receptor synthesis&#46;</p><p id="par0335" class="elsevierStylePara elsevierViewall">Various expert consensus guidelines recommend starting statin treatment at 8&#8211;10 years of age in children with HeFH&#44; and at the time of diagnosis in children with HoFH&#44; before 5 years of age and no later than 8&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">27</span></a></p><p id="par0340" class="elsevierStylePara elsevierViewall">The statins shown below are currently approved by the <span class="elsevierStyleItalic">US Food and Drug Administration</span> and the <span class="elsevierStyleItalic">European Medicines Agency</span> &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#46; Pitavastatin has not been approved in children&#44; although a recently-published study demonstrates its safety in patients aged 6&#8211;17 years&#46;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">44</span></a> Various studies have shown the short-term safety and efficacy of statins&#46; A follow-up study was recently published on a cohort of 214 children with FH treated with pravastatin for 10 months&#44; demonstrating that the long-term safety does not differ from that reported in adult patients&#46;<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">45</span></a></p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0345" class="elsevierStylePara elsevierViewall">Treatment should be started if LDL-C levels are &#8805;190<span class="elsevierStyleHsp" style=""></span>mg&#47;dL or &#8805;160<span class="elsevierStyleHsp" style=""></span>mg&#47;dL if accompanied by one of the following conditions&#58; history of PCVD in a first-degree relative&#59; other diseases suffered by the child that involve elevated CV risk &#40;diabetes&#44; metabolic syndrome&#44; hypertension&#44; lupus erythematosus&#44; organ transplant and Kawasaki disease&#41;&#59; or in the event of high CV risk factors &#40;obesity&#44; smoking&#44; increased Lp&#40;a&#41; and homocysteinaemia&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">13</span></a></p><p id="par0350" class="elsevierStylePara elsevierViewall">When statin treatment is initiated&#44; the lowest recommended dose should be chosen&#44; which can then be adjusted according to response and tolerance&#46; In any case&#44; combination therapy with other drugs &#40;ezetimibe or resins&#41; may be necessary in order to achieve the therapeutic objectives&#46; <a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a> shows the parameters to be monitored&#46; Although side effects are uncommon&#44; the following have been reported&#58; cramps&#44; muscle pain&#44; gastrointestinal effects and elevated transaminases&#46; No growth hormone or sex hormone abnormalities has been reported&#46;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">46</span></a></p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia><p id="par0355" class="elsevierStylePara elsevierViewall">If transaminases are observed to be three times the upper limit of normal&#44; the dose should be reduced or withdrawn and an additional follow-up check should be arranged&#46; If the child undertakes intensive exercise&#44; we recommend stopping exercise at least three days before blood draws in order to avoid elevated CPK levels secondary to exercise&#46;</p><p id="par0360" class="elsevierStylePara elsevierViewall">In children that require pharmacological treatment due to other concomitant diseases&#44; it is important to recognise that cytochrome P450 uses the drug to be metabolised&#46; The decision regarding the type of statin to be chosen for initiating treatment will depend on this fact&#46; If the child presents with kidney failure&#44; the statin of choice shall be atorvastatin&#44; as its excretion by the kidneys is minimal&#46; The paediatrician should be aware of potential drug interactions with statins and must avoid prescribing routine drugs like macrolides&#46;</p><p id="par0365" class="elsevierStylePara elsevierViewall">Girls of childbearing age should be advised on different methods of contraception and must be informed that accidental pregnancies are to be avoided&#46; In case of accidental pregnancy&#44; pharmacological treatment must be immediately suspended&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Efficacy and tolerance of ezetimibe</span><p id="par0370" class="elsevierStylePara elsevierViewall">Ezetimibe is a drug that acts by selectively inhibiting cholesterol and plant sterol absorption in the small intestine&#44; without affecting the absorption of fat-soluble vitamins or other substances&#46;</p><p id="par0375" class="elsevierStylePara elsevierViewall">In general&#44; it is a second-line&#44; lipid-lowering drug that is usually administered in combination with a statin&#46; It is indicated in monotherapy in the event of statin intolerance&#46; Experience of the drug in children is somewhat limited&#59; the studies that have been conducted have only evaluated its short-and medium-term safety and efficacy and&#44; as such&#44; more studies are needed to assess its long-term profile<a class="elsevierStyleCrossRefs" href="#bib0535"><span class="elsevierStyleSup">47&#44;48</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#46;</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Efficacy and tolerance of resins</span><p id="par0380" class="elsevierStylePara elsevierViewall">Ion-exchange resins act by inhibiting bile acid absorption in the intestine&#46;<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">49</span></a></p><p id="par0385" class="elsevierStylePara elsevierViewall">There are a number of resins that are currently available on the market &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#46; However&#44; gastrointestinal intolerance and difficult ingestion can lead to discontinuation of treatment&#46; In an attempt to reduce this problem&#44; dissolving the powder or granules in fruit juice and taking them before meals is recommended&#46; It must be remembered that the drug cannot be administered together with other treatments &#40;1<span class="elsevierStyleHsp" style=""></span>h before or 4<span class="elsevierStyleHsp" style=""></span>h after&#41;&#46; Prolonged treatments may alter the absorption of fat-soluble vitamins &#40;A&#44; D&#44; E and K&#41; and folic acid&#44; so supplements may be required&#46; The most common side effect is constipation&#44; so a fibre-rich diet will be recommended&#46;</p><p id="par0390" class="elsevierStylePara elsevierViewall">Colesevelam is the newest resin to be placed on the market&#46; Its safety and efficacy have been assessed in children with HeFH between the ages of 10 and 17 years&#46; Due to its presentation&#44; it has a seemingly greater tolerance than the other resins&#46;<a class="elsevierStyleCrossRefs" href="#bib0550"><span class="elsevierStyleSup">50&#44;51</span></a></p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Efficacy and tolerability of PCSK9 inhibitors</span><p id="par0395" class="elsevierStylePara elsevierViewall">PCSK9 is a protein segregated by the hepatocytes&#44; which intervenes in regulating cholesterol metabolism&#46;<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">52</span></a></p><p id="par0400" class="elsevierStylePara elsevierViewall">PCSK9 inhibition reduces the number of receptors that are due to be degraded and thus increases their density on the cell surface&#44; with the subsequent reduction of plasma cholesterol&#46;</p><p id="par0405" class="elsevierStylePara elsevierViewall">Anti-PCSK9 antibodies are a new group of drugs that have already proven their excellent short-term safety and efficacy&#46; At present&#44; evolocumab and alirocumab have been approved in Spain and are indicated for the FH population in which therapeutic objectives are not met at the maximum tolerated dose of lipid-lowering drugs&#46;<a class="elsevierStyleCrossRefs" href="#bib0565"><span class="elsevierStyleSup">53&#44;54</span></a></p><p id="par0410" class="elsevierStylePara elsevierViewall">Children with HoFH have also been included in clinical trials with evolocumab&#46; Additional LDL-C reductions have been observed in children carrying defective genes&#59; however&#44; no effect was observed on carriers of receptor-negative mutations&#46;<a class="elsevierStyleCrossRefs" href="#bib0575"><span class="elsevierStyleSup">55&#44;56</span></a> PCSK9 inhibitors will undoubtedly be a therapeutic option for a very specific group of children with HoFH&#44; which could even lead to fewer LDL apheresis sessions for those administered this treatment &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#46;</p></span></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Future therapeutic innovations</span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Lomitapide</span><p id="par0415" class="elsevierStylePara elsevierViewall">Lomitapide is an oral inhibitor of the microsomal triglyceride transfer protein present in the endoplasmic reticulum of hepatocytes and enterocytes&#46; It has been approved by the <span class="elsevierStyleItalic">US Food and Drug Administration</span> and the <span class="elsevierStyleItalic">European Medicines Agency</span> for the treatment of HoFH&#46; Compared to the standard therapy&#44; one study found lomitapide to reduce the LDL-C concentration by up to a further 50&#37; after 12 months of follow-up&#46;<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">57</span></a> Side effects are very common and primarily of a gastrointestinal nature&#46; Elevated transaminases and the onset of hepatic steatosis have been reported&#44; which must therefore be monitored throughout treatment&#46;</p><p id="par0420" class="elsevierStylePara elsevierViewall">In Spain&#44; the first clinical experience with lomitapide has been published&#46;<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">58</span></a> There are still no data available on children&#44; although it is approved on a &#8220;compassionate use&#8221; basis&#46;</p></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Mipomersen</span><p id="par0425" class="elsevierStylePara elsevierViewall">Mipomersen is an antisense oligonucleotide that inhibits the mRNA transcription of ApoB&#46; The reduction in ApoB synthesis gives rise to a decrease in intrahepatic VLDL and&#44; consequently&#44; LDL-C&#46; A long-term study was recently published where treatment with this drug was associated with a reduction in CV events in patients with FH&#46;<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">59</span></a></p><p id="par0430" class="elsevierStylePara elsevierViewall">It has not been approved by the <span class="elsevierStyleItalic">European Medicines Agency</span> due to the onset of numerous adverse effects&#44; principally comprising local reactions at the injection site and elevated transaminases&#46;<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">60</span></a></p></span></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Homozygous familial hypercholesterolaemia</span><p id="par0435" class="elsevierStylePara elsevierViewall">HoFH is the form with the most severe expression&#46; If they do not receive treatment&#44; most children will go on to develop arteriosclerosis before 20 years of age and their life expectancy will not exceed 30 years&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">27</span></a></p><p id="par0440" class="elsevierStylePara elsevierViewall">Starting treatment as early as possible is recommended in an attempt to delay the onset of CV disease&#46; The therapeutic objective is the same in children with HeFH&#59; however&#44; in the event of established CV disease&#44; the objective should be LDL-C levels&#60;70<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#46; These objectives are very hard to achieve&#46; An oral lipid-lowering treatment should be administered as early as possible from 2 years of age&#44; combining statins with ezetimibe or resins&#46; Despite this&#44; the LDL-C reductions observed will be very mild&#46;</p><p id="par0445" class="elsevierStylePara elsevierViewall">Most children will need to receive LDL apheresis&#46; This is a method of extracorporeal ApoB-lipoprotein elimination&#44; obtaining further LDL-C reductions of 55&#8211;70&#37;&#46; This reduction is temporary&#44; so weekly or fortnightly sessions should be performed&#46; It is recommended that apheresis be initiated in children below 5 years of age and never later than 8&#46; LDL apheresis is well tolerated&#44; with adverse effects reported in less than 5&#37; of the procedures&#46; One problem in younger children is venous access&#46; On occasions&#44; fitting a central access device will be necessary&#44; with complications in the form of infections and thrombosis having been reported&#46;</p><p id="par0450" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows the LDL-C reductions observed according to the treatment administered to children with HoFH&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">27</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0455" class="elsevierStylePara elsevierViewall">Children with HoFH should be transferred to specialist units for treatment&#46;</p></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conclusions</span><p id="par0460" class="elsevierStylePara elsevierViewall">FH is a hereditary genetic disorder with a high CV risk&#46; In order to prevent morbidity and mortality in later life&#44; detection should be initiated in childhood&#46; We believe that the paediatrician plays a vital role and universal screening in children under the age of 10 years would be advisable&#44; although this practice is not accepted across the board at the present time&#46; As an alternative&#44; we recommend opportunistic screening&#46; Direct cascade and selective screening should be performed in routine clinical practice&#46; Reverse cascade screening has also proven to be an effective tool&#44; and TC should be assessed with all blood draws performed&#46; Healthy lifestyle habits should be encouraged in children from a young age and pharmacological treatment initiated whenever indicated&#46; The performance of genetic testing is important in order to stratify risk&#44; but also as a method of family adherence&#46;</p><p id="par0465" class="elsevierStylePara elsevierViewall">Children with FH should be transferred to specialist referral units with the capacity to perform genetic testing and experience in managing such cases&#46; Children with HoFH will require intensive pharmacological treatment at maximum doses alongside LDL apheresis&#46;</p></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Ethical responsibilities</span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Protection of people and animals</span><p id="par0470" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were conducted on human beings or animals for this research&#46;</p></span><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Data confidentiality</span><p id="par0475" class="elsevierStylePara elsevierViewall">The authors declare that no patient data is contained in this article&#46;</p></span><span id="sec0150" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Right to privacy and informed consent</span><p id="par0480" class="elsevierStylePara elsevierViewall">The authors declare that no patient data is contained in this article&#46;</p></span></span><span id="sec0155" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Conflicts of interest</span><p id="par0485" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "titulo" => "Introduction"
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          "titulo" => "Children and adolescents with familial hypercholesterolaemia"
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                  "titulo" => "Fat"
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          "titulo" => "Homozygous familial hypercholesterolaemia"
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    "fechaRecibido" => "2016-10-06"
    "fechaAceptado" => "2016-11-04"
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            0 => "Familial hypercholesterolemia"
            1 => "Children"
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            0 => "Hipercolesterolemia familiar"
            1 => "Ni&#241;os"
            2 => "Cribado"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Familial hypercholesterolemia &#40;FH&#41; is the most common genetic disorder in childhood&#44; but in most cases is not detected&#46; High levels of low-density lipoprotein cholesterol are present since the child&#39;s birth and this fact will suppose silent development of early atherosclerosis&#46; In cases of homozygous FH&#44; the coronary disease will appear before 20s and in cases of heterozygous FH will occur in middle age&#46; Despite published data&#44; there is not agreement about how and when perform the screening&#46; Familial history of early cardiovascular disease plus presence of hypercholesterolemia in parents is crucial for detection and diagnosis&#46; Actually&#44; it is topic of discussion that it is necessary to achieve therapeutic goals from an early age to improve prognosis&#46; Lifestyle changes are the first line therapy&#46; Statins are the lipid-lowering drugs of choice but the optimal age to start therapy it is still controversial&#46; In this article&#44; current recommendations of expert consensus guidelines about the management and new line therapies of child and adolescents are reviewed&#46;</p></span>"
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      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La hipercolesterolemia familiar &#40;HF&#41; es el trastorno gen&#233;tico m&#225;s prevalente en edad pedi&#225;trica&#59; sin embargo&#44; en la inmensa mayor&#237;a de los casos pasa totalmente desapercibida&#46; La elevaci&#243;n del colesterol ligado a las lipoprote&#237;nas de baja densidad presente desde el nacimiento comportar&#225; el desarrollo silente de arteriosclerosis de forma precoz&#46; Este hecho podr&#225; manifestarse en forma de enfermedad coronaria antes de los 20 a&#241;os en la HF homocigota o en la edad media de la vida en la HF heterocigota&#46; A pesar de las evidencias cient&#237;ficas&#44; no existe un acuerdo com&#250;n de c&#243;mo y cu&#225;ndo se debe hacer el cribado&#44; hecho que se pone de manifiesto al revisar las diferentes gu&#237;as de consenso de expertos&#46; La historia familiar de enfermedad cardiovascular prematura&#44; junto con la presencia de hipercolesterolemia en uno de los progenitores&#44; es crucial en la detecci&#243;n y el diagn&#243;stico&#46; Alcanzar los objetivos terap&#233;uticos desde edades tempranas es un elemento clave en el pron&#243;stico&#44; aunque sigue siendo un tema de amplio debate&#46; El primer eslab&#243;n del tratamiento siempre ser&#225;n las recomendaciones de h&#225;bitos de vida cardiosaludables&#46; En la actualidad&#44; existe controversia sobre a qu&#233; edad se debe iniciar el tratamiento farmacol&#243;gico&#44; siendo las estatinas el f&#225;rmaco de primera elecci&#243;n&#46; En este art&#237;culo se revisan las recomendaciones actuales de las gu&#237;as de consenso de expertos en el manejo del ni&#241;o y adolescente con HF&#44; as&#237; como las nuevas terapias emergentes&#46;</p></span>"
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      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Plana N&#44; Rodr&#237;guez-Borjabad C&#44; Ibarretxe D&#44; Masana L&#46; Hipercolesterolemia familiar en la infancia y la adolescencia&#58; una realidad oculta&#46; Clin Invest Arterioscler&#46; 2017&#59;29&#58;129&#8211;140&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">LDL cholesterol reduction according to the treatment administered to children with homozygous familial hypercholesterolaemia&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">27</span></a></p>"
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        "etiqueta" => "Table 1"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Society&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Country&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Screening&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Target LDL-C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Start of treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">National Institute for Health and Clinical Excellence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">United Kingdom&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Direct cascade&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Based on the Simon Broome criteria<br>TC<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>260<span class="elsevierStyleHsp" style=""></span>mg&#47;dL or LDL-C<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>155<span class="elsevierStyleHsp" style=""></span>mg&#47;dL in patients<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>16 years of age<br>TC<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>290<span class="elsevierStyleHsp" style=""></span>mg&#47;dL or LDL-C<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>190<span class="elsevierStyleHsp" style=""></span>mg&#47;dL in patients<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>16 years of age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50&#37; reduction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10 years and above&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2008&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Spanish Association of Paediatrics&#8217; therapeutic approach to FH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Spain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Selective screening from 2 years of age in obese patients&#44; patients with a history of premature coronary heart disease or parents with FH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not specified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">From 10 years of age and in cases where LDL is &#62;500<span class="elsevierStyleHsp" style=""></span>mg&#47;dL at 8 years of age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Belgian consensus for FH treatment in children and young adults&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Belgium&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Non-universal screening<br>Selective screening<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>2 years of age<br>Screening if risk factors present at &#62;2 years of age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LDL-C<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>200<span class="elsevierStyleHsp" style=""></span>mg&#47;dL<br>LDL-C<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>160<span class="elsevierStyleHsp" style=""></span>mg&#47;dL<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>family history<br>LDL-C<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>135<span class="elsevierStyleHsp" style=""></span>mg&#47;dL with familial mutation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LDL-C<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>130<span class="elsevierStyleHsp" style=""></span>mg&#47;dL between 10 and 14 years of age and&#47;or 30&#37; reduction<br>LDL-C<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>130<span class="elsevierStyleHsp" style=""></span>mg&#47;dL between 14 and 18 years of age and&#47;or 50&#37; reduction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10 years and above&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2011&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Paediatric guidelines on cardiovascular risk in children and adolescents&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">USA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Selective screening in patients &#8805;2 years of age<br>Universal screening in patients aged 9&#8211;11 years&#44; with TC&#44; HDL-C and non-HDL-C or full lipid profile<br>Universal screening in patients aged 17&#8211;21 years&#44; with full lipid profile&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Children or adolescents with fasting LDL-C<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>160<span class="elsevierStyleHsp" style=""></span>mg&#47;dL or &#62;190<span class="elsevierStyleHsp" style=""></span>mg&#47;dL of non-HDL-C&#46; These patients must have relatives with the condition&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50&#37; reduction in LDL-C or LDL-C<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>130<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10 years and above&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2011&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Paediatric FH screening in Europe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Europe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Universal screening in patients aged 1&#8211;9 years&#44; during the vaccination phase&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not specified&#44; although the importance of detecting the mutation in parents is explained&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not specified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8 years and above&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Consensus of the European Atherosclerosis Society and the European Society of Cardiology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Europe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Direct cascade if a family member has FH&#44; a TC level<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>230<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#44; a history of premature coronary heart disease&#44; tendinous xanthomas or premature sudden cardiac death<br>Universal cascade screening is recommended&#44; as performed in Slovenia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">In patients &#60;10 years of age with LDL-C levels<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>160<span class="elsevierStyleHsp" style=""></span>mg&#47;dL with a family history of PCVD or a parent with hypercholesterolaemia<br>If the parent tests positive for the FH mutation and the child&#39;s LDL-C is &#62;135<span class="elsevierStyleHsp" style=""></span>mg&#47;dL<br>The criteria of the <span class="elsevierStyleItalic">Dutch Lipid Clinic Network</span> are used&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Maintain LDL-C levels &#60;135<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Between 8 and 10 years of age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Expert consensus of the European Atherosclerosis Society specific to children and adolescents &#40;European Society of Cardiology&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Europe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Consider universal screening<br>Direct cascade screening from 5 years of age or before if homozygosis is suspected&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LDL-C<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>190<span class="elsevierStyleHsp" style=""></span>mg&#47;dL or LDL-C<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>160<span class="elsevierStyleHsp" style=""></span>mg&#47;dL with a family history of PCVD and&#47;or a positive genetic test<br>LDL-C<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>130<span class="elsevierStyleHsp" style=""></span>mg&#47;dL and a positive family genetic test<br>&#42;<span class="elsevierStyleItalic">Children diagnosed with FH should have their Lp&#40;a&#41; measured so their risk may be stratified</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">In children between 8 and 10 years of age&#44; reduce LDL-C by 50&#37; compared to pre-treatment levels<br>Children<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>10 years&#44; especially if there are additional CV risk factors or LDL-C levels<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>130<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Between 8 and 10 years of age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Primary Care consensus document for FH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Spain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Selective screening before 8 years of age<br>TC should be tested from 2 years of age if there is family history of FH<br>If a relative presents a known mutation&#44; perform genetic testing if LDL-C levels are &#62;150<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LDL-C<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>190<span class="elsevierStyleHsp" style=""></span>mg&#47;dL or LDL-C<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>150<span class="elsevierStyleHsp" style=""></span>mg&#47;dL where there is a family history of PCVD and&#47;or hypercholesterolaemia in one of the parents and&#47;or a genetic confirmation in one of the parents&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LDL-C<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>160<span class="elsevierStyleHsp" style=""></span>mg&#47;dL in patients under 14 years and LDL-C<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>130<span class="elsevierStyleHsp" style=""></span>mg&#47;dL from 14 years and above&#44; except in the event of other CVRFs or a history of PCVD in the affected parent&#44; as provisions may be stricter in these cases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10 years and above&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Scientific statement on FH from the American Heart Association&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">USA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Universal screening between 6 and 12 years of age<br>Indirect cascade&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LDL-C<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>160<span class="elsevierStyleHsp" style=""></span>mg&#47;dL<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>family history and&#47;or genetic mutation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LDL-C<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>100 or 130<span class="elsevierStyleHsp" style=""></span>mg&#47;dL or achieve a 50&#37; reduction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Between 8 and 10 years of age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Review on the diagnosis and treatment of FH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">London&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Direct cascade using the proband Opportunistic cascade&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LDL-C<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>155<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#44; having ruled out secondary causes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Maintain LDL-C levels<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>135<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not specified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Optimisation of FH treatment in children and adolescents&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Netherlands&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Universal screening<br>Selective screening based on family history&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LDL-C<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>190<span class="elsevierStyleHsp" style=""></span>mg&#47;dL on 2 occasions after a 3-month diet period<br>Family history of PCVD and&#47;or high cholesterol in first-degree relatives together with LDL-C<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>160<span class="elsevierStyleHsp" style=""></span>mg&#47;dL<br>In case of a mutation in a first-degree relative and if the patient presents with an LDL-C level<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>130<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50&#37; reduction<br>Children aged 8&#8211;10 years with LDL-C<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>154<span class="elsevierStyleHsp" style=""></span>mg&#47;dL<br>Children<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>10 years of age with LDL-C<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>135<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Between 8 and 10 years of age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Paediatric guidelines on managing FH from the National Lipid Association expert panel&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">USA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Familial cascade&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LDL-C<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>160<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50&#37; reduction in LDL-C or &#60;100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Between 8 and 10 years of age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2016&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Summary of the main guidelines on familial hypercholesterolaemia in childhood and adolescence&#46;</p>"
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      ]
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        "etiqueta" => "Table 2"
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          "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Data expressed as mg&#47;dL&#46;</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Source</span>&#58; Mor&#225;is-L&#243;pez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">24</span></a></p>"
          "tablatextoimagen" => array:1 [
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Acceptable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Limit&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Total cholesterol</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;170&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">170&#8211;199&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8805;200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">LDL-C</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;110&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">110&#8211;129&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8805;130&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Triglycerides</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>0&#8211;9 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">75&#8211;99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8805;100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>10&#8211;19 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">90&#8211;129&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8805;130&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">HDL-C</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#62;45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&#8211;45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">ApoB</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">90&#8211;109&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8805;110&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Reference lipid profile in childhood and adolescence&#46;</p>"
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        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at3"
            "detalle" => "Table "
            "rol" => "short"
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        "tabla" => array:1 [
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Drugs&#58; amiodarone&#44; corticosteroids&#44; anabolic steroids&#44; cyclosporin&#44; phenobarbital&#44; progestogens&#44; phenytoin&#44; thiazides&#44; etc&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Anorexia nervosa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cholestasis&#58; biliary cirrhosis&#44; biliary atresia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Growth hormone deficiency&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Endocrine disorders&#58; hypothyroidism&#44; hypopituitarism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Kidney diseases&#58; nephrotic syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Idiopathic hypercalcaemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Acute intermittent porphyria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Deposition diseases&#58; glycogenosis&#44; Tay-Sachs&#44; Gaucher&#44; Niemann-Pick&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dietary factors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Secondary causes of hypercholesterolaemia in childhood&#46;</p>"
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      4 => array:8 [
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        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
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            "identificador" => "at4"
            "detalle" => "Table "
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        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Child with LDL-C &#8805;130</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">mg&#47;dL and one of the following&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>History of PCVD in first-degree relatives &#60;55 years of age and second-degree relatives &#60;50 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Parent with total cholesterol levels &#62;300<span class="elsevierStyleHsp" style=""></span>mg&#47;dL or receiving lipid-lowering treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Lack of information on the parents&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>One parent affected by FH with a clinical or genetic diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Suspicion criteria for familial hypercholesterolaemia in childhood and adolescence&#46;</p>"
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        "detalles" => array:1 [
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            "identificador" => "at5"
            "detalle" => "Table "
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        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">F&#225;rmacos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Dose&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LDL-C reduction&#44; &#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Resins</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Cholestyramine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;6 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#8211;8<span class="elsevierStyleHsp" style=""></span>g&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#8211;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Colestipol&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;6 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#8211;15<span class="elsevierStyleHsp" style=""></span>g&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#8211;15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Colesevelam&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;10 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1875&#8211;3750<span class="elsevierStyleHsp" style=""></span>g&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#8211;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Statins</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Pravastatin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;8&#8211;13 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#8211;20<span class="elsevierStyleHsp" style=""></span>mg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#8211;30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&#8211;18 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#8211;40<span class="elsevierStyleHsp" style=""></span>mg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#8211;36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Fluvastatin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;9&#8211;13 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#8211;20<span class="elsevierStyleHsp" style=""></span>mg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&#8211;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&#8211;18 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#8211;40<span class="elsevierStyleHsp" style=""></span>mg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&#8211;26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Simvastatin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;10 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#8211;40<span class="elsevierStyleHsp" style=""></span>mg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&#8211;41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Atorvastatin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;10 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#8211;20<span class="elsevierStyleHsp" style=""></span>mg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">36&#8211;41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Rosuvastatin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#8211;9 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#8211;10<span class="elsevierStyleHsp" style=""></span>mg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">41&#8211;47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;10 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#8211;20<span class="elsevierStyleHsp" style=""></span>mg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">41&#8211;52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Absorption inhibitors</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Ezetimibe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;10 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10<span class="elsevierStyleHsp" style=""></span>mg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;12 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">140<span class="elsevierStyleHsp" style=""></span>mg&#47;14 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&#8211;30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Monitor CPK if the patient reports myalgia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Monitor glucose in patients receiving high statin doses and who are obese&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Growth and pubertal development check&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Yearly check once the therapeutic objective has been met&nbsp;\t\t\t\t\t\t\n
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos