The prevention of adult cardiovascular disease must begin in childhood: evidence and imperative.

Growing evidence from the past seven decades indicates that atherosclerosis begins in youth and progresses in response to exposure to cardiovascular risk factors, which contribute to the development of cardiovascular disease in later life. A long-term randomized clinical trial lasting at least 50 years and involving screening and follow-up of children across their lifespan would provide the highest level of evidence to determine the lifelong influence of cardiovascular risk factors on cardiovascular disease risk but such an approach is not feasible. However, much can be learned from observing patients with familial hypercholesterolaemia. Those patients who were treated at a young age remained event-free into adulthood, beyond the ages at which their affected parent, who initiated treatment at a much later age, experienced their first cardiovascular event. The evidence is less certain for other types of dyslipidaemia and other cardiovascular risk factors, including high blood pressure. Nonetheless, the strategy of waiting until later in adulthood to screen and intervene, often after a non-fatal cardiovascular disease event has already occurred, might no longer seem prudent. In this Review, we summarize the growing body of evidence supporting intensified efforts to identify cardiovascular risk factors in children and young adults, and to identify knowledge gaps among this cohort such as the optimal timing and strategy for blood lipid screening.