Evaluation of AAP guidelines for cholesterol screening in youth: Project HeartBeat!

BACKGROUND: The American Academy of Pediatrics (AAP) criterion for screening for hypercholesterolemia in children is family history of hypercholesterolemia or cardiovascular disease or BMI > or =85th percentile. This paper aims to determine the sensitivity, specificity, and positive predictive value (PPV) of dyslipidemia screening using AAP criteria along with either family history or BMI.
METHODS: Height, weight, plasma total cholesterol, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), triglycerides, and family history were obtained for 678 children aged 8, 11, and 14 years, enrolled from 1991 to 1993 in Project HeartBeat!. Sensitivity, specificity, and PPV screening of each lipid component using family history alone, BMI > or =85th percentile alone, or family history and/or BMI > or =85th percentile, were calculated using 2008 AAP criteria (total cholesterol, LDL-C, and triglycerides > or =90th percentile; HDL-C <10th percentile).
RESULTS: Sensitivity of detecting abnormal total cholesterol, LDL-C, HDL-C, and triglycerides using family history alone ranged from 38% to 43% and significantly increased to 54%-66% using family history and/or BMI. Specificity significantly decreased from approximately 65% to 52%, and there were no notable changes in PPV. In black children, cholesterol screening using the BMI > or =85th percentile criterion had higher sensitivity than when using the family history criterion. In nonblacks, family history and/or BMI > or =85th percentile had greater sensitivity than family history alone.
CONCLUSIONS: When the BMI screening criterion was used along with the family history criterion, sensitivity increased, specificity decreased, and PPV changed trivially for detection of dyslipidemia. Despite increased screening sensitivity by adding the BMI criterion, a clinically significant number of children still may be misclassified.