Kids and Cholesterol

In adults, statins lower cholesterol, but they also make plaque less unstable, so it doesn't break off and cause a heart attack. Is that right?
Statins have other effects than lowering lipid levels. What they don't do in high-risk adults is make atherosclerosis go away. That's been confirmed in a number of studies. So the question is, how do they work? If they don't make the plaque disappear, what are they doing? They're doing something to diminish the risk that the plaque would rupture or erode or bleed.

But kids don't usually have that kind of high-risk unstable plaque.
We're asking statins to do something different in kids—we're asking statins to retard the progression or development of plaque. In other words, we're asking the drug to do something it hasn't been shown to do in adults. There are some studies in adolescents with familial hypercholesterolemia [a rare, inherited form of extremely high cholesterol] that use ultrasound of the carotid artery to show that statins prevent the thickening of the carotid artery.

What exactly is the link between high cholesterol in childhood and risk of heart disease later on?
I don't think we're at the point of looking at a child and being able to predict the risk of coronary heart disease with great certainty. What we do know is that there's a lot of evidence that links childhood risk factors with future risk. There's epidemiological evidence that heart attack risk in adulthood is related to children's cholesterol levels in a population. The societies with the highest risk of heart disease tend to be the societies where the children in that population have high serum levels.

I'm assuming the U.S. is right at the top?
We're somewhere in the middle, actually. Then if you take adults who have had heart attacks, their children tend to have high cholesterol. And in autopsy studies of kids who died in accidents, they've found that in adolescents, just like in adults, there's a link between the numbers for cholesterol levels and the amount of plaque in the arteries.

You wrote last year in Pediatrics that "the results of adult statin studies are so striking and favorable that one is tempted to generalize them to children, adolescents and adults at low risk; however, there are important caveats in the extrapolation of these results to children." What are those caveats?
The short-term safety studies in children are very reassuring, but what we don't know and need to study is whether statins have unique long-term effects on developing organisms. We don't know about that yet. The statin trials have been too short to say one way or the other. That's why we have to be cautious about translating their broad use. … Now, there's an argument that you do have to take risks to make progress in medicine. But those risks have to be very carefully calculated. We need to create a registry of children treated with statins, or obligate the pharmaceutical industry to do so, or else we have to have a large federally funded study, because the current way we monitor these children for long-term effects isn't adequate. The problem is that the timeline for any study is just so long that no one has conceived of a way of creating one.

You'd have to follow kids for 50 years.
Exactly. This kind of data will probably eventually emerge from electronic health databases, but it will not be a randomized controlled trial.