"The child is father of the man" (William Wordsworth, 1802).

The occurrence of atherosclerosis at an early age has long been the subject of curiosity and wonder. Isn't it remarkable that 65 of 140 combat soldiers who died as a result of injuries sustained in World War I had increased coronary atherosclerotic plaques at a mean age of 27.7 years (1)? How interesting is it that grossly visible lesions not causing obstruction were present in 35% of 300 Korean War fatalities at an average of 22.1 years of age, with 39% having 10% to 90% stenosis, 3% total occlusion, and only 23% free of grossly visible coronary lesions (2)! This curiosity quickly dissipates despite confirmation by subsequent landmark studies (3,4) and evidence that favorable risk factor profiles early in life are associated with better outcomes (5,6). Attention is quickly turned to the detection and treatment of atherosclerosis in adults, at which point our best efforts produce only a 30% reduction in events compared with placebo in the primary prevention population (7). Although dissatisfied with this inadequate event reduction , the cardiology community has been reluctant to seek earlier risk stratification and intervention for several reasons. First, because an event has not yet occurred, the cardiologist believes that there still exists an ample window of opportunity to lower low-density lipoprotein cholesterol (LDL-C) and blood pressure (BP) and institute beneficial lifestyle changes. Second, there is great reluctance to implement aggressive evaluation and treatment of children and adolescents for whom the specter of potential lifelong statin treatment and drastic lifestyle changes appears daunting. Third, there is no consensus regarding the appropriate risk stratification tool for this age group. Finally, there have been no data supporting the effect of treating childhood/ adolescent risk factors on adult events. However, there have been several studies linking childhood risk factors to subclinical atherosclerosis. In the Muscatine study (8) of 346 men and 379 women 33 to 42 years of age, multivariable analysis using measurements performed at 8 to 11 years of age identified total cholesterol as a significant risk factor for increased carotid intima-media thickness (CIMT) in men (odds ratio: 1.47) and women (odds ratio: 1.71). The Cardiovascular Risk in Young Finns Study (9) evaluated 2,229 white adults 24 to 39 years of age who were examined at 3 to 18 years of age and underwent CIMT 21 years later. In age-and sex-adjusted multivariable models, CIMT in adulthood was significantly associated with childhood LDL-C levels (p ϭ …