Lipid Luminations: Memorial to Bill Neal - A Pioneer in Pediatric Cardiovascular Health

William “Bill” Neal, MD (1940-2021), was a pediatric cardiologist who pioneered the “Coronary Artery Risk Detection in Appalachian Communities” (CARDIAC) initiative.(1)

CARDIAC is a comprehensive school-based risk factor surveillance, intervention, and research initiative designed to address the mortality and morbidity associated with obesity, diabetes, and cardiovascular disease (CVD) in West Virginia—a predominantly rural population with the highest prevalence of CVD in the United States. At the inception of CARDIAC in 1998, Neal hypothesized that to prevent heart disease in future generations, universal cholesterol screening of children would be superior to simply using family history of premature coronary heart disease (CHD) as a screening tool.(2) During the study, other risk factors of CVD, such as body mass index (BMI), blood pressure, and evidence of pre-diabetes, were also included in screening.(3)

Between 1998 and 2017, as a component of the West Virginia Rural Health Education Partnership (WVRHEP), CARDIAC deployed health science students to screen over 200,000 school children from every corner of the state for CVD-related risk factors. Parents were informed about their children’s CVD risk and encouraged to practice and pass on heart-healthy behavior, including a balanced diet, active lifestyle, and more exercise.(4) For children at the highest risk of CVD, referrals were made to primary care providers. Cascade screening of parents was also employed, particularly for those children identified as having probable genetic dyslipidemia. Apart from primary health outcomes, CARDIAC utilized these health science students in medically underserved populations within Appalachia, thereby seeking to also address a physician shortage in rural communities as well as the screening objectives.

Data from CARDIAC was considered by National Heart, Lung, and Blood Institute 2011 Expert Panel that recommended all children between the ages of 9-11 years undergo universal cholesterol screening, regardless of health status and family history.(5,6) The American Academy of Pediatrics (AAP) and American Heart Association subsequently endorsed the recommendation. Almost one-quarter of all children in CARDIAC had abnormal blood lipids. Of these children, over 600 fifth grade children were identified with probable genetic dyslipidemia and 37% within a study subset would not have been classified as having possible (LDL > 160 mg/dL) familial hypercholesterolemia (FH) according to guidelines at the time. This data bolstered Neal’s hypothesis that family screening of premature CHD was an insufficient marker of at-risk children. We now know that long-term use of statin, started in childhood, is well-tolerated, slows the progression of carotid-intima-media thickness, and significantly reduces the risk of ASCVD-related events. Other shorter-term studies have also shown the efficacy and safety of statin use in children.(7) The results of Neal’s work provide critical guidance in helping us identify at-risk children who would benefit from early treatment (8). Accordingly, the recommendation endorsed by AAP has been heightened in importance, particularly as we explore the optimum timing and use of lipid-lowering therapies in children with FH.(9)

For two decades, CARDIAC was supported by the West Virginia legislature, Center for Disease Control and Prevention, National Institute of Health, and the Benedum Foundation. It was the largest youth-based project of its kind in the nation and its impact spurred new public policy and public health strategies to lower cholesterol and Heart Disease risk (10). Indeed, CARDIAC was the recipient of many national awards, including recognition by the American Public Health Association and the National Rural Health Association. Dr. Neal was internationally recognized for this work and served in many leadership positions over the years, including as Chairman of the board of the Familial Hypercholesterolemia Foundation from 2016 to 2020. With his guidance, the Foundation has led and funded multiple population health projects of all sorts--machine-learning, genetic testing, and cascade screening--to address gaps in familial hypercholesterolemia diagnosis and treatment.(11,12) We are all indebted to Dr. Neal and his colleagues for their pioneering efforts in West Virginia that carried across the world.(13)

Disclosure statement: Mr. Sheth has no financial disclosures to report. Dr. Agarwala has no financial disclosures to report. Dr. Wilson has received honoraria from Alexion.
References are listed in the 2021-2022 Winter LipidSpin .pdf on www.lipid.org