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Tagi VM, Mainieri F, Chiarelli F. Hypertension in Patients with Insulin Resistance: Etiopathogenesis and Management in Children. Int J Mol Sci 2022; 23:ijms23105814. [PMID: 35628624 PMCID: PMC9144705 DOI: 10.3390/ijms23105814] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 05/19/2022] [Accepted: 05/19/2022] [Indexed: 11/16/2022] Open
Abstract
Insulin resistance (IR) is a key component in the etiopathogenesis of hypertension (HS) in patients with diabetes mellitus (DM). Several pathways have been found to be involved in this mechanism in recent literature. For the above-mentioned reasons, treatment of HS should be specifically addressed in patients affected by DM. Two relevant recently published guidelines have stressed this concept, giving specific advice in the treatment of HS in children belonging to this group: the European Society of HS guidelines for the management of high blood pressure in children and adolescents and the American Academy of Pediatrics Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Our aim is to summarize the main pathophysiological mechanisms through which IR causes HS and to highlight the specific principles of treatment of HS for children with DM.
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Stambolliu E, Kollias A, Bountzona I, Ntineri A, Servos G, Vazeou A, Stergiou GS. Nighttime Home Blood Pressure in Children: Association with Ambulatory Blood Pressure and Preclinical Organ Damage. Hypertension 2021; 77:1877-1885. [PMID: 33840203 DOI: 10.1161/hypertensionaha.121.17016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Emelina Stambolliu
- Hypertension Center STRIDE-7, National and Kapodistrian University of Athens, School of Medicine, Third Department of Medicine, Sotiria Hospital, Athens, Greece (E.S., A.K., I.B., A.N., G.S.S.)
| | - Anastasios Kollias
- Hypertension Center STRIDE-7, National and Kapodistrian University of Athens, School of Medicine, Third Department of Medicine, Sotiria Hospital, Athens, Greece (E.S., A.K., I.B., A.N., G.S.S.)
| | - Ioanna Bountzona
- Hypertension Center STRIDE-7, National and Kapodistrian University of Athens, School of Medicine, Third Department of Medicine, Sotiria Hospital, Athens, Greece (E.S., A.K., I.B., A.N., G.S.S.)
| | - Angeliki Ntineri
- Hypertension Center STRIDE-7, National and Kapodistrian University of Athens, School of Medicine, Third Department of Medicine, Sotiria Hospital, Athens, Greece (E.S., A.K., I.B., A.N., G.S.S.)
| | - George Servos
- Hypertension Center STRIDE-7, National and Kapodistrian University of Athens, School of Medicine, Third Department of Medicine, Sotiria Hospital, Athens, Greece (E.S., A.K., I.B., A.N., G.S.S.)
| | - Andriani Vazeou
- First Department of Pediatrics (A.V.), P. & A. Kyriakou Children's Hospital, Athens, Greece
| | - George S Stergiou
- Hypertension Center STRIDE-7, National and Kapodistrian University of Athens, School of Medicine, Third Department of Medicine, Sotiria Hospital, Athens, Greece (E.S., A.K., I.B., A.N., G.S.S.)
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Stergiou GS, Bountzona I, Alamara C, Vazeou A, Kollias A, Ntineri A. Reproducibility of Office and Out-of-Office Blood Pressure Measurements in Children: Implications for Clinical Practice and Research. Hypertension 2021; 77:993-1000. [PMID: 33423526 DOI: 10.1161/hypertensionaha.120.16531] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study aimed to evaluate the reproducibility of office (OBP), ambulatory (ABP), and home blood pressure (HBP) measurements in children and adolescents, and their implications in diagnosing hypertension in clinical practice and in pediatric hypertension research. Apparently healthy children and adolescents referred for suspected hypertension were included. Measurements of 2-visit OBP, 7-day HBP, and 24-hour ABP were performed twice, 1 to 6 months apart. Reproducibility was quantified using the SD of differences between repeated measurements. The sample size of clinical trials comparing the efficacy of antihypertensive drugs using each method was calculated. Fifty-eight individuals were analyzed (mean age, 13.0±2.9 years, 60.3% boys). The reproducibility of 24-hour ABP (SD of differences 5.7/4.5 systolic/diastolic) and HBP (5.9/5.0 mm Hg) were comparable and superior to that of visit-2 OBP (9.2/7.8) and awake (6.7/5.5) or asleep ABP (7.6/6.1). As a consequence, a parallel-group comparative trial aiming to detect a difference in the effect of 2 drugs of 10 mm Hg systolic BP, would require 36 participants when using OBP measurements, 14 using 24-hour ABP, and 15 using HBP (102/34/42 respectively for detecting a 5 mm Hg difference in diastolic BP). For a crossover design trial, the corresponding sample sizes are 9/3/4 for systolic BP and 26/9/11 for diastolic, respectively. These data suggest that in children and adolescents 24-hour ABP and 7-day HBP have similar reproducibility, superior to OBP and daytime or asleep ABP. These findings have major implications in diagnosing hypertension in children in clinical practice and in designing clinical research trials in pediatric hypertension.
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Affiliation(s)
- George S Stergiou
- Hypertension Center STRIDE-7, National and Kapodistrian University of Athens, School of Medicine, Third Department of Medicine, Sotiria Hospital, Athens, Greece
| | - Ioanna Bountzona
- Hypertension Center STRIDE-7, National and Kapodistrian University of Athens, School of Medicine, Third Department of Medicine, Sotiria Hospital, Athens, Greece
| | - Christina Alamara
- Hypertension Center STRIDE-7, National and Kapodistrian University of Athens, School of Medicine, Third Department of Medicine, Sotiria Hospital, Athens, Greece
| | - Andriani Vazeou
- Hypertension Center STRIDE-7, National and Kapodistrian University of Athens, School of Medicine, Third Department of Medicine, Sotiria Hospital, Athens, Greece
| | - Anastasios Kollias
- Hypertension Center STRIDE-7, National and Kapodistrian University of Athens, School of Medicine, Third Department of Medicine, Sotiria Hospital, Athens, Greece
| | - Angeliki Ntineri
- Hypertension Center STRIDE-7, National and Kapodistrian University of Athens, School of Medicine, Third Department of Medicine, Sotiria Hospital, Athens, Greece
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Chrysaidou K, Chainoglou A, Karava V, Dotis J, Printza N, Stabouli S. Secondary Hypertension in Children and Adolescents: Novel Insights. Curr Hypertens Rev 2020; 16:37-44. [PMID: 31038068 DOI: 10.2174/1573402115666190416152820] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 03/31/2019] [Accepted: 04/01/2019] [Indexed: 12/25/2022]
Abstract
Hypertension is a significant risk factor for cardiovascular morbidity and mortality, not only in adults, but in youths also, as it is associated with long-term negative health effects. The predominant type of hypertension in children is the secondary hypertension, with the chronic kidney disease being the most common cause, however, nowadays, there is a rising incidence of primary hypertension due to the rising incidence of obesity in children. Although office blood pressure has guided patient management for many years, ambulatory blood pressure monitoring provides useful information, facilitates the diagnosis and management of hypertension in children and adolescents, by monitoring treatment and evaluation for secondary causes or specific phenotypes of hypertension. In the field of secondary hypertension, there are numerous studies, which have reported a strong association between different determinants of 24-hour blood pressure profile and the underlying cause. In addition, in children with secondary hypertension, ambulatory blood pressure monitoring parameters offer the unique advantage to identify pediatric low- and high-risk children for target organ damage. Novel insights in the pathogenesis of hypertension, including the role of perinatal factors or new cardiovascular biomarkers, such as fibroblast growth factor 23, need to be further evaluated in the near future.
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Affiliation(s)
- Katerina Chrysaidou
- 1st Department of Pediatrics, Aristotle University Thessaloniki, Hippokratio General Hospital, Thessaloniki, Greece
| | - Athanasia Chainoglou
- 1st Department of Pediatrics, Aristotle University Thessaloniki, Hippokratio General Hospital, Thessaloniki, Greece
| | - Vasiliki Karava
- 1st Department of Pediatrics, Aristotle University Thessaloniki, Hippokratio General Hospital, Thessaloniki, Greece
| | - John Dotis
- 1st Department of Pediatrics, Aristotle University Thessaloniki, Hippokratio General Hospital, Thessaloniki, Greece
| | - Nikoleta Printza
- 1st Department of Pediatrics, Aristotle University Thessaloniki, Hippokratio General Hospital, Thessaloniki, Greece
| | - Stella Stabouli
- 1st Department of Pediatrics, Aristotle University Thessaloniki, Hippokratio General Hospital, Thessaloniki, Greece
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Measurement of SBP at home by parents using hand-held Doppler device and aneroid sphygmomanometer: a single-centre experience. J Hypertens 2020; 39:904-910. [PMID: 33273193 DOI: 10.1097/hjh.0000000000002736] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We taught parents to use at home a hand-held Doppler device and aneroid sphygmomanometer for SBPmeasurement (HDBPM). METHODS Retrospective study including all children referred to evaluate hypertension over a 6-year period. Each child underwent HDBPM measurements performed by parents while awake over 2 weeks with three measurements performed twice daily. RESULTS Of n = 155 children, 145 (93.5%) were successful and aged median (interquartile range) 2.48 (1.01, 5.12) years, including 85 boys. Overall, there were 25, 19, 30 and 26% aged less than 1, 1 to less than 2, 2 to less than 5 and at least 5 years old, respectively. Seventy-eight (54%) had been referred for confirming diagnosis and 67 (46%) for ongoing monitoring of treated hypertension. Following HDBPM, 70 of 78 (90%) patients in the 'Diagnosis subgroup' were observed to have normal blood pressure (BP). In the monitoring subgroup, treated hypertension that required no medication changes was recorded in 35 of 67 (52%) and medication changed in 32 of 67 (48%), [increased, decreased or changed] in 22, 6 and 5%, respectively. In 10 of 67 (15%) medication was weaned and stopped completely following HDBPM. None of the children required admission to hospital to evaluate their BP level or manage hypertension. CONCLUSION Out-of-office BP monitoring using HDBPM is acceptable to children and families of young children when parents are taught to measure BP and supported by health professionals. We report evidence of the feasibility and clinical utility of HDBPM in a challenging population of children who are either too young or unable to tolerate 24-h ambulatory BP monitoring for both the diagnosis and ongoing management of clinically relevant hypertension.
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Dionne JM. Evidence Gaps in the Identification and Treatment of Hypertension in Children. Can J Cardiol 2020; 36:1384-1393. [PMID: 32502426 DOI: 10.1016/j.cjca.2020.02.076] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 02/06/2020] [Indexed: 01/03/2023] Open
Abstract
The ultimate goal of recognizing and treating hypertension in childhood is to prevent target-organ damage during childhood and to reduce the risk of adulthood cardiovascular disease. The quality of evidence to guide blood pressure management in children is lower than in adult medicine, yet some common findings support clinical practice recommendations. Oscillometric devices are increasingly replacing manual blood pressure measurements, but evidence shows that readings are not equivalent between the 2 methods. In addition, multiple blood pressure readings are needed before diagnosing a child with hypertension, but the optimal number and timing are still being determined. The recent American Academy of Pediatrics blood pressure guideline has revised the normative data tables and included threshold blood pressure limits which seem to identify children with higher cardiovascular risks. Threshold limits vary between guidelines, and the most accurate threshold has yet to be determined. Lifestyle modifications are a cornerstone of hypertension management, but the optimal diet and physical activity changes for beneficial effect are not known. When pharmacotherapy is needed, physicians have used drugs from all antihypertensive classes in children, yet only a few classes have been systematically studied. The long-term cardiovascular consequences of elevated blood pressure during childhood are under investigation and it seems that the lower the childhood blood pressure the better and that the rate of change during childhood is predictive of adulthood disease. With much still to learn, this article summarizes the evidence and the evidence gaps for the diagnosis, investigation, management, and outcomes of pediatric hypertension.
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Affiliation(s)
- Janis M Dionne
- Division of Nephrology, Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver, British Columbia, Canada.
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Stergiou G, Stambolliu E, Bountzona I, Ntineri A, Kollias A, Vazeou A, Soldatou A. Home Blood Pressure Monitoring in Children and Adolescents: Systematic Review of Evidence on Clinical Utility. Curr Hypertens Rep 2019; 21:64. [PMID: 31240404 DOI: 10.1007/s11906-019-0967-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE OF REVIEW For the accurate diagnosis and management of hypertension, out-of-office blood pressure evaluation using ambulatory (ABPM) or home monitoring (HBPM) is currently recommended. In children, there is considerable evidence on the clinical utility of ABPM, whereas the evidence on HBPM is limited. This systematic review presents (i) the benefits of HBPM in children; (ii) the evidence on normal range, diagnostic accuracy, and relationship with preclinical organ damage; and (iii) guidance for devices, monitoring schedule, and interpretation. RECENT FINDINGS HBPM is a useful adjunct to the conventional office measurements for the evaluation of children with suspected or treated hypertension. HBPM is feasible in children and has good reproducibility, diagnostic accuracy and acceptability by users, and relatively low cost. Thus, it has greater potential for widespread and long-term use than ABPM, which is more expensive and often not available or not tolerated. Automated monitors that have been clinically validated specifically in children should be used with appropriate cuff size. HBPM for 7 days (minimum 3) with duplicate morning and evening measurements (minimum 12 readings) should be performed in children with suspected or treated hypertension before each office visit. Until more data become available, in case of diagnostic disagreement between office blood pressure and HBPM, treatment decisions should be based on ABPM. HBPM is clinically useful in children with hypertension. More research is needed on its clinical application, and more automated devices need to be clinically validated in this population.
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Affiliation(s)
- George Stergiou
- Hypertension Center STRIDE-7, National and Kapodistrian University of Athens, School of Medicine, Third Department of Medicine, Sotiria Hospital, Athens, Greece.
| | - Emelina Stambolliu
- Hypertension Center STRIDE-7, National and Kapodistrian University of Athens, School of Medicine, Third Department of Medicine, Sotiria Hospital, Athens, Greece
| | - Ioanna Bountzona
- Hypertension Center STRIDE-7, National and Kapodistrian University of Athens, School of Medicine, Third Department of Medicine, Sotiria Hospital, Athens, Greece
| | - Angeliki Ntineri
- Hypertension Center STRIDE-7, National and Kapodistrian University of Athens, School of Medicine, Third Department of Medicine, Sotiria Hospital, Athens, Greece
| | - Anastasios Kollias
- Hypertension Center STRIDE-7, National and Kapodistrian University of Athens, School of Medicine, Third Department of Medicine, Sotiria Hospital, Athens, Greece
| | - Andriani Vazeou
- First Department of Pediatrics, P&A Kyriakou Children's Hospital, Athens, Greece
| | - Alexandra Soldatou
- Second Department of Pediatrics, National and Kapodistrian University of Athens, School of Medicine, P&A Kyriakou Children's Hospital, Athens, Greece
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Samuel JP, Tyson JE, Green C, Bell CS, Pedroza C, Molony D, Samuels J. Treating Hypertension in Children With n-of-1 Trials. Pediatrics 2019; 143:e20181818. [PMID: 30842257 PMCID: PMC6564074 DOI: 10.1542/peds.2018-1818] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/14/2019] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES Clinicians prescribe antihypertensive medication to children with primary hypertension, but without data to define a particular choice as first-line therapy. A one-size-fits-all approach may not be appropriate for these patients. Our aim was to develop a personalized approach to hypertension treatment, using repeated ambulatory blood pressure monitoring (ABPM) in n-of-1 trials (single-patient randomized crossover trials). METHODS Children undergoing hypertension management at a single pediatric referral center were offered participation in an n-of-1 trial with repeated ABPM to compare 3 commonly used medications. The medication producing the greatest blood pressure reduction, and without unacceptable side effects, was selected as the preferred therapy for the individual. RESULTS Forty-two children agreed to participate; 7 were normotensive without medication; and 3 failed to complete one treatment cycle. Of the remaining 32 patients, lisinopril was preferred for 16, amlodipine for 8, hydrochlorothiazide for 4, and 4 had uncontrolled blood pressure on maximum doses of monotherapy. In conservative Bayesian analyses, the proportion of patients who preferred lisinopril was 49% (95% credible interval [CrI]: 32% to 69%), 24% (95% CrI: 12% to 41%) preferred amlodipine, and 12% (95% CrI: 4% to 26%) preferred hydrochlorothiazide. The preferred therapy for the majority (67%) of African American participants was lisinopril. Unacceptable side effects were reported in 24% of assessments for hydrochlorothiazide, 16% for lisinopril, and 13% for amlodipine. CONCLUSIONS No single medication was preferred for more than half of hypertensive children. n of-1 trials with repeated ABPM may promote better informed and individualized decisions in pediatric hypertension management.
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Affiliation(s)
| | | | | | | | | | - Don Molony
- McGovern Medical School at University of Texas Health Science Center, Houston, Texas
| | - Joshua Samuels
- Department of Pediatrics
- McGovern Medical School at University of Texas Health Science Center, Houston, Texas
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Comparability of oscillometric to simultaneous auscultatory blood pressure measurement in children. Blood Press Monit 2019; 24:83-88. [DOI: 10.1097/mbp.0000000000000367] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Home blood pressure monitoring in pediatric hypertension: the US perspective and a plan for action. Hypertens Res 2018; 41:662-668. [PMID: 30054592 DOI: 10.1038/s41440-018-0078-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 03/08/2018] [Accepted: 03/08/2018] [Indexed: 11/09/2022]
Abstract
The 2017 US guidelines for pediatric hypertension place considerable emphasis on blood pressure measurements, which are the cornerstone for hypertension diagnosis and management. It is recognized that when the diagnosis of hypertension is based solely on office blood pressure measurements, many children are misclassified (over- or underdiagnosed). Therefore, out-of-office blood pressure evaluations using ambulatory or home blood pressure monitoring are often necessary to obtain an accurate diagnosis. Strong evidence for the diagnostic and clinical value of ambulatory blood pressure monitoring in children has justified its central role in decision making in recent pediatric recommendations. However, ambulatory blood pressure monitoring is not widely accessible in primary care. There is little evidence for home blood pressure monitoring in children, yet this method is widely available and feasible for the evaluation of elevated blood pressure in children. This article presents a case for using home blood pressure monitoring for the management of children with suspected or treated hypertension in clinical practice in comparison to using office measurements or ambulatory blood pressure monitoring, as well as its optimal application. More research on home blood pressure monitoring in children is urgently needed.
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Lande MB, Batisky DL, Kupferman JC, Samuels J, Hooper SR, Falkner B, Waldstein SR, Szilagyi PG, Wang H, Staskiewicz J, Adams HR. Neurocognitive Function in Children with Primary Hypertension after Initiation of Antihypertensive Therapy. J Pediatr 2018; 195:85-94.e1. [PMID: 29398058 PMCID: PMC5869096 DOI: 10.1016/j.jpeds.2017.12.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 10/26/2017] [Accepted: 12/04/2017] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To determine the change in neurocognitive test performance in children with primary hypertension after initiation of antihypertensive therapy. STUDY DESIGN Subjects with hypertension and normotensive control subjects had neurocognitive testing at baseline and again after 1 year, during which time the subjects with hypertension received antihypertensive therapy. Subjects completed tests of general intelligence, attention, memory, executive function, and processing speed, and parents completed rating scales of executive function. RESULTS Fifty-five subjects with hypertension and 66 normotensive control subjects underwent both baseline and 1-year assessments. Overall, the blood pressure (BP) of subjects with hypertension improved (24-hour systolic BP load: mean baseline vs 1 year, 58% vs 38%, P < .001). Primary multivariable analyses showed that the hypertension group improved in scores of subtests of the Rey Auditory Verbal Learning Test, Grooved Pegboard, and Delis-Kaplan Executive Function System Tower Test (P < .05). However, the control group also improved in the same measures with similar effects sizes. Secondary analyses by effectiveness of antihypertensive therapy showed that subjects with persistent ambulatory hypertension at 1 year (n = 17) did not improve in subtests of Rey Auditory Verbal Learning Test and had limited improvement in Grooved Pegboard. CONCLUSIONS Overall, children with hypertension did not improve in neurocognitive test performance after 1 year of antihypertensive therapy, beyond that also seen in normotensive controls, suggesting improvements with age or practice effects because of repeated neurocognitive testing. However, the degree to which antihypertensive therapy improves BP may affect its impact upon neurocognitive function.
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Affiliation(s)
- Marc B. Lande
- Department of Pediatrics, University of Rochester, Rochester, NY
| | | | | | - Joshua Samuels
- Department of Pediatrics, McGovern Medical School at UTHealth, Houston, TX
| | - Stephen R. Hooper
- Departments of Allied Health Sciences and Psychiatry, University of North Carolina, Chapel Hill, North Carolina
| | - Bonita Falkner
- Department of Pediatrics, Thomas Jefferson University, Philadelphia, PA
| | - Shari R. Waldstein
- Department of Psychology, University of Maryland, Baltimore County, Baltimore, MD
| | - Peter G. Szilagyi
- Department of Pediatrics, University of California at Los Angeles (UCLA), Los Angeles, CA
| | - Hongyue Wang
- Department of Biostatistics, University of Rochester, Rochester, NY
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Veloudi P, Blizzard CL, Srikanth VK, Schultz MG, Sharman JE. Influence of blood pressure level and age on within-visit blood pressure variability in children and adolescents. Eur J Pediatr 2018; 177:205-210. [PMID: 29204850 DOI: 10.1007/s00431-017-3049-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 11/07/2017] [Accepted: 11/09/2017] [Indexed: 11/26/2022]
Abstract
UNLABELLED Blood pressure (BP) is variable in children and this could affect BP assessment, but the magnitude of within-visit BP variability (BPV) over consecutive measurements has never been investigated. This study aimed to determine the direction and magnitude of, and factors affecting, within-visit BPV in children and adolescents. BP was recorded among 3047 children (aged 12 years [95%CI 12, 13], males 52%) from the 2011-2013 Australian Health Survey. BPV was defined as the absolute difference (∆SBPABS) between the first (SBP1) and second systolic BP (SBP2) and the overall variability in three measures when available (SBPV). On average, ∆SBPABS was 6.7 mmHg (95%CI 6.3, 7.0) and SBPV was 8.2% (95%CI 7.8, 8.6). ∆SBPABS was greater with higher BP levels but lower with older age. From first to second measurements, SBP decreased in 58% (95%CI 56, 60), did not change in 10% (95%CI 9, 12), and increased in 32% (95%CI 29, 34) of the population. CONCLUSIONS BP is highly variable in children and adolescents, with the magnitude of variability being associated with both age and BP level. SBP increases on repeat measurement in a substantial proportion of the population. The optimal protocol of BP assessment to address this increased BPV needs to be determined. What is Known: • Diagnosis of elevated blood pressure (BP) is based on strict probabilistic criteria, the difference between the 90th (pre-hypertension) and 95th (hypertension) percentiles only being 3-4 mmHg. • BP variability could affect BP classification among children and adolescents. What is New: • The magnitude of BP change among children and adolescents is highly affected by BP level and age. • BP does not always drop on consecutive measurements, and evidence-based BP assessment protocols should be established to avoid misdiagnosis of hypertension.
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Affiliation(s)
- Panagiota Veloudi
- Menzies Institute for Medical Research, University of Tasmania, Liverpool Street, Hobart, TAS, 7000, Australia
| | - Christopher L Blizzard
- Menzies Institute for Medical Research, University of Tasmania, Liverpool Street, Hobart, TAS, 7000, Australia
| | - Velandai K Srikanth
- Menzies Institute for Medical Research, University of Tasmania, Liverpool Street, Hobart, TAS, 7000, Australia
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash Medical Centre, Melbourne, VIC, Australia
| | - Martin G Schultz
- Menzies Institute for Medical Research, University of Tasmania, Liverpool Street, Hobart, TAS, 7000, Australia
| | - James E Sharman
- Menzies Institute for Medical Research, University of Tasmania, Liverpool Street, Hobart, TAS, 7000, Australia.
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Updated Guideline May Improve the Recognition and Diagnosis of Hypertension in Children and Adolescents; Review of the 2017 AAP Blood Pressure Clinical Practice Guideline. Curr Hypertens Rep 2017; 19:84. [DOI: 10.1007/s11906-017-0780-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, de Ferranti SD, Dionne JM, Falkner B, Flinn SK, Gidding SS, Goodwin C, Leu MG, Powers ME, Rea C, Samuels J, Simasek M, Thaker VV, Urbina EM. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics 2017; 140:peds.2017-1904. [PMID: 28827377 DOI: 10.1542/peds.2017-1904] [Citation(s) in RCA: 1875] [Impact Index Per Article: 267.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
These pediatric hypertension guidelines are an update to the 2004 "Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents." Significant changes in these guidelines include (1) the replacement of the term "prehypertension" with the term "elevated blood pressure," (2) new normative pediatric blood pressure (BP) tables based on normal-weight children, (3) a simplified screening table for identifying BPs needing further evaluation, (4) a simplified BP classification in adolescents ≥13 years of age that aligns with the forthcoming American Heart Association and American College of Cardiology adult BP guidelines, (5) a more limited recommendation to perform screening BP measurements only at preventive care visits, (6) streamlined recommendations on the initial evaluation and management of abnormal BPs, (7) an expanded role for ambulatory BP monitoring in the diagnosis and management of pediatric hypertension, and (8) revised recommendations on when to perform echocardiography in the evaluation of newly diagnosed hypertensive pediatric patients (generally only before medication initiation), along with a revised definition of left ventricular hypertrophy. These guidelines include 30 Key Action Statements and 27 additional recommendations derived from a comprehensive review of almost 15 000 published articles between January 2004 and July 2016. Each Key Action Statement includes level of evidence, benefit-harm relationship, and strength of recommendation. This clinical practice guideline, endorsed by the American Heart Association, is intended to foster a patient- and family-centered approach to care, reduce unnecessary and costly medical interventions, improve patient diagnoses and outcomes, support implementation, and provide direction for future research.
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Affiliation(s)
- Joseph T Flynn
- Dr. Robert O. Hickman Endowed Chair in Pediatric Nephrology, Division of Nephrology, Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington;
| | - David C Kaelber
- Departments of Pediatrics, Internal Medicine, Population and Quantitative Health Sciences, Center for Clinical Informatics Research and Education, Case Western Reserve University and MetroHealth System, Cleveland, Ohio
| | - Carissa M Baker-Smith
- Division of Pediatric Cardiology, School of Medicine, University of Maryland, Baltimore, Maryland
| | - Douglas Blowey
- Children's Mercy Hospital, University of Missouri-Kansas City and Children's Mercy Integrated Care Solutions, Kansas City, Missouri
| | - Aaron E Carroll
- Department of Pediatrics, School of Medicine, Indiana University, Bloomington, Indiana
| | - Stephen R Daniels
- Department of Pediatrics, School of Medicine, University of Colorado-Denver and Pediatrician in Chief, Children's Hospital Colorado, Aurora, Colorado
| | - Sarah D de Ferranti
- Director, Preventive Cardiology Clinic, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Janis M Dionne
- Division of Nephrology, Department of Pediatrics, University of British Columbia and British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Bonita Falkner
- Departments of Medicine and Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Susan K Flinn
- Consultant, American Academy of Pediatrics, Washington, District of Columbia
| | - Samuel S Gidding
- Cardiology Division Head, Nemours Cardiac Center, Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Celeste Goodwin
- National Pediatric Blood Pressure Awareness Foundation, Prairieville, Louisiana
| | - Michael G Leu
- Departments of Pediatrics and Biomedical Informatics and Medical Education, University of Washington, University of Washington Medicine and Information Technology Services, and Seattle Children's Hospital, Seattle, Washington
| | - Makia E Powers
- Department of Pediatrics, School of Medicine, Morehouse College, Atlanta, Georgia
| | - Corinna Rea
- Associate Director, General Academic Pediatric Fellowship, Staff Physician, Boston's Children's Hospital Primary Care at Longwood, Instructor, Harvard Medical School, Boston, Massachusetts
| | - Joshua Samuels
- Departments of Pediatrics and Internal Medicine, McGovern Medical School, University of Texas, Houston, Texas
| | - Madeline Simasek
- Pediatric Education, University of Pittsburgh Medical Center Shadyside Family Medicine Residency, Clinical Associate Professor of Pediatrics, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, and School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Vidhu V Thaker
- Division of Molecular Genetics, Department of Pediatrics, Columbia University Medical Center, New York, New York; and
| | - Elaine M Urbina
- Preventive Cardiology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
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Hypertension Canada's 2017 Guidelines for the Diagnosis, Assessment, Prevention, and Treatment of Pediatric Hypertension. Can J Cardiol 2017; 33:577-585. [DOI: 10.1016/j.cjca.2017.03.007] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 03/08/2017] [Accepted: 03/08/2017] [Indexed: 12/18/2022] Open
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Stergiou GS, Boubouchairopoulou N, Kollias A. Accuracy of Automated Blood Pressure Measurement in Children: Evidence, Issues, and Perspectives. Hypertension 2017; 69:1000-1006. [PMID: 28438903 DOI: 10.1161/hypertensionaha.116.08553] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- George S Stergiou
- From the Hypertension Center STRIDE-7, National and Kapodistrian University of Athens, School of Medicine, Third Department of Medicine, Sotiria Hospital, Athens, Greece.
| | - Nadia Boubouchairopoulou
- From the Hypertension Center STRIDE-7, National and Kapodistrian University of Athens, School of Medicine, Third Department of Medicine, Sotiria Hospital, Athens, Greece
| | - Anastasios Kollias
- From the Hypertension Center STRIDE-7, National and Kapodistrian University of Athens, School of Medicine, Third Department of Medicine, Sotiria Hospital, Athens, Greece
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Jardim TV, Gaziano TA, Nascente FM, Carneiro CDS, Morais P, Roriz V, Mendonça KL, Póvoa TIR, Barroso WKS, Sousa ALL, Jardim PCV. Office blood pressure measurements with oscillometric devices in adolescents: a comparison with home blood pressure. Blood Press 2017; 26:272-278. [PMID: 28376650 DOI: 10.1080/08037051.2017.1312279] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE Compare multiple in office BP measurements in adolescents using an oscillometric device with out-of-office blood pressure measurements (home blood pressure monitoring - HBPM). MATERIALS AND METHODS Office measurements were performed with validated semi-automatic devices twice (3 minutes interval) in two different moments (1 week apart), with a total of four readings. These BP readings were named R1, R2, R3 and R4 (following the sequence they were performed), FDM (mean of two readings on first day) and SDM (mean of two readings on second day) and SRM (R2-R4 means). The HBPM protocol included two day-time and two evening-time measurements over 6 days. RESULTS A total of 1024 students between 12 and 17 years were included (mean age 14.68 years; 52.4% females). The mean systolic blood pressure (SBP) values of R2, SDM and SRM were similar to HBPM values. Regarding diastolic blood pressure (DBP) HBPM value was different than R4. High SBP and DBP correlation coefficients with HBPM values were found for R2, SDM and SRM values. CONCLUSION The second office BP measurement performed with an oscilometric device in adolescents was comparable to HBPM values, suggesting that two office readings might be suitable to rule out hypertension in this age group.
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Affiliation(s)
- Thiago Veiga Jardim
- a Hypertension League - Federal University of Goias , Goiânia , GO , Brazil.,b Brigham & Women's Hospital - Division of Cardiovascular Medicine , Boston , MA , USA.,c Harvard TH Chan School of Public Health - Department of Health Policy and Management , Center for Health Decision Science , Boston , MA , USA
| | - Thomas A Gaziano
- b Brigham & Women's Hospital - Division of Cardiovascular Medicine , Boston , MA , USA.,c Harvard TH Chan School of Public Health - Department of Health Policy and Management , Center for Health Decision Science , Boston , MA , USA
| | | | | | - Polyana Morais
- a Hypertension League - Federal University of Goias , Goiânia , GO , Brazil
| | - Vanessa Roriz
- a Hypertension League - Federal University of Goias , Goiânia , GO , Brazil
| | | | - Thaís Inácio Rolim Póvoa
- a Hypertension League - Federal University of Goias , Goiânia , GO , Brazil.,d School of Physical Education and Therapy (ESEFFEGO) , State University of Goiás (UEG) , Goiânia , GO , Brazil
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Woroniecki RP, Kahnauth A, Panesar LE, Supe-Markovina K. Left Ventricular Hypertrophy in Pediatric Hypertension: A Mini Review. Front Pediatr 2017; 5:101. [PMID: 28553631 PMCID: PMC5425592 DOI: 10.3389/fped.2017.00101] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 04/20/2017] [Indexed: 12/17/2022] Open
Abstract
Adults with arterial hypertension (HTN) have stroke, myocardial infarction, end-stage renal disease (ESRD), or die at higher rates than those without. In children, HTN leads to target organ damage, which includes kidney, brain, eye, blood vessels, and heart, which precedes "hard outcomes" observed in adults. Left ventricular hypertrophy (LVH) or an anatomic and pathologic increase in left ventricular mass (LVM) in response to the HTN is a pediatric surrogate marker for HTN-induced morbidity and mortality in adults. This mini review discusses current definitions, clinically relevant methods of LVM measurements and normalization methods, its epidemiology, management, and issue of reversibility in children with HTN. Pediatric definition of LVH and abnormal LVM is not uniformed. With multiple definitions, prevalence of pediatric HTN-induced LVH is difficult to ascertain. In addition while in adults cardiac magnetic resonance imaging is considered "the gold standard" for LVM and LVH determination, pediatric data are limited to "special populations": ESRD, transplant, and obese children. We summarize available data on pediatric LVH treatment and reversibility and offer future directions in addressing LVH in children with HTN.
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Affiliation(s)
- Robert P Woroniecki
- Division of Pediatric Nephrology and Hypertension, Stony Brook Children's Hospital, School of Medicine, Stony Brook, NY, USA
| | | | - Laurie E Panesar
- Division of Pediatric Cardiology, Stony Brook Children's Hospital, School of Medicine, Stony Brook, NY, USA
| | - Katarina Supe-Markovina
- Division of Pediatric Nephrology and Hypertension, Stony Brook Children's Hospital, School of Medicine, Stony Brook, NY, USA
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Binka E, Mendley S, Gaskin P, Himes C, Jinadu L, Baker-Smith CM. Description of Antihypertensive Medication Use in a Pediatric Practice: Single and Multiple Antihypertensive Medication Therapy. J Clin Hypertens (Greenwich) 2016; 19:90-97. [PMID: 27481566 DOI: 10.1111/jch.12879] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 06/02/2016] [Accepted: 06/09/2016] [Indexed: 12/31/2022]
Abstract
Prescription of multiple antihypertensive medications for the treatment of essential hypertension (HTN) has been well described in adults but not in children and adolescents. The authors describe the frequency with which children with essential HTN are prescribed a single vs two or more concomitantly administered antihypertensive medications. They also describe demographic features and comorbidities associated with the prescription of a single vs multiple antihypertensive medications. Multiple antihypertensive medication use in the management of pediatric HTN, as in the management of adult HTN, is not uncommon. In this single-center, retrospective study of 113 children with essential HTN, 28% of children were concomitantly prescribed two or more antihypertensive medications for poorly controlled blood pressure following prescription of a single medication. Demographic and comorbid conditions associated with the prescription of more than one antihypertensive medication include advanced hypertensive stage, race, and a family history of HTN.
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Affiliation(s)
- Edem Binka
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD
| | - Susan Mendley
- Division of Pediatric Nephrology, University of Maryland School of Medicine, Baltimore, MD
| | - Peter Gaskin
- Division of Pediatric Cardiology, University of Maryland School of Medicine, Baltimore, MD
| | - Carisa Himes
- Division of Pediatric Cardiology, University of Maryland School of Medicine, Baltimore, MD
| | - Laide Jinadu
- Division of Pediatric Nephrology, University of Maryland School of Medicine, Baltimore, MD
| | - Carissa M Baker-Smith
- Division of Pediatric Cardiology, University of Maryland School of Medicine, Baltimore, MD
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21
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Rao G. Diagnosis, Epidemiology, and Management of Hypertension in Children. Pediatrics 2016; 138:peds.2015-3616. [PMID: 27405770 DOI: 10.1542/peds.2015-3616] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/02/2016] [Indexed: 11/24/2022] Open
Abstract
National guidelines for the diagnosis and management of hypertension in children have been available for nearly 40 years. Unfortunately, knowledge and recognition of the problem by clinicians remain poor. Prevalence estimates are highly variable because of differing standards, populations, and blood pressure (BP) measurement techniques. Estimates in the United States range from 0.3% to 4.5%. Risk factors for primary hypertension include overweight and obesity, male sex, older age, high sodium intake, and African American or Latino ancestry. Data relating hypertension in childhood to later cardiovascular events is currently lacking. It is known that BP in childhood is highly predictive of BP in adulthood. Compelling data about target organ damage is available, including the association of hypertension with left ventricular hypertrophy, carotid-intima media thickness, and microalbuminuria. Guidelines from both the United States and Europe include detailed recommendations for diagnosis and management. Diagnostic standards are based on clinic readings, ambulatory BP monitoring is useful in confirming diagnosis of hypertension and identifying white-coat hypertension, masked hypertension, and secondary hypertension, as well as monitoring response to therapy. Research priorities include the need for reliable prevalence estimates based on diverse populations and data about the long-term impact of childhood hypertension on cardiovascular morbidity and mortality. Priorities to improve clinical practice include more education among clinicians about diagnosis and management, clinical decision support to aid in diagnosis, and routine use of ambulatory BP monitoring to aid in diagnosis and to monitor response to treatment.
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Affiliation(s)
- Goutham Rao
- Ambulatory Primary Care Innovations Group (APCIG) and Department of Family Medicine, NorthShore University HealthSystem, Evanston, Illinois; Pritzker School of Medicine, University of Chicago, Chicago, Illinois; and Department of Family Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
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Wirix AJG, Verheul J, Groothoff JW, Nauta J, Chinapaw MJM, Kist-van Holthe JE. Screening, diagnosis and treatment of hypertension in obese children: an international policy comparison. J Nephrol 2016; 30:119-125. [PMID: 26940338 PMCID: PMC5316390 DOI: 10.1007/s40620-016-0277-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 01/31/2016] [Indexed: 12/11/2022]
Abstract
Hypertension in obese children may require a different diagnostic and treatment approach from that for children with secondary hypertension, yet there is neither consensus nor a clear guideline. The aim of this study was to assess how obese children with hypertension are currently diagnosed and treated by paediatric nephrologists, what obstacles exist and what can be improved. In the period May–November 2014, an online questionnaire was sent to all members of the European Society for Paediatric Nephrology (n = 2148). Questions focused on current practices and obstacles regarding screening, diagnosis and treatment of hypertension in obese children. A total of 214 paediatric nephrologists responded. Although nearly 100 % agreed that screening of obese children for hypertension is indicated, it was current practice in only 56 % of participating countries; 88 % of respondents diagnosed hypertension with 24-h ambulatory blood pressure measurement. Diagnostics used to rule out causes or consequences of hypertension varied among the respondents; they included, in particular, the use of serum renin/aldosterone, urine sodium/potassium, and dimercaptosuccinic acid scan. Concerning treatment, 45 % of respondents preferred to start treatment with a lifestyle program, 2 % with antihypertensive medication, and 40 % with both. For 73 % of respondents, angiotensin-converting enzyme-inhibitors or angiotensin receptor blockers were the drugs of first choice. The findings of this study emphasize the urgent need for an international guideline for screening, diagnosis and treatment of hypertension in obese children.
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Affiliation(s)
- Aleid J G Wirix
- Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, van der Boechorststraat 7, 1081BT, Amsterdam, The Netherlands.
| | - Jelle Verheul
- Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, van der Boechorststraat 7, 1081BT, Amsterdam, The Netherlands
| | - Jaap W Groothoff
- Department of Paediatric Nephrology, Emma Children's Hospital/Academic Medical Center, Amsterdam, The Netherlands
| | - Jeroen Nauta
- Department of Paediatric Nephrology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Mai J M Chinapaw
- Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, van der Boechorststraat 7, 1081BT, Amsterdam, The Netherlands
| | - Joana E Kist-van Holthe
- Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, van der Boechorststraat 7, 1081BT, Amsterdam, The Netherlands
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Samuel JP, Samuels JA, Brooks LE, Bell CS, Pedroza C, Molony DA, Tyson JE. Comparative effectiveness of antihypertensive treatment for older children with primary hypertension: study protocol for a series of n-of-1 randomized trials. Trials 2016; 17:16. [PMID: 26746195 PMCID: PMC4706696 DOI: 10.1186/s13063-015-1142-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 12/22/2015] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Children are increasingly being diagnosed with primary hypertension. The absence of comparative effectiveness research of antihypertensive medications in children has contributed to considerable differences in prescribing practices among physicians treating children with primary hypertension. Even if parallel-group trials had established a best overall choice for most of these children, the best medication for an individual may differ from the best overall medication. METHODS/DESIGN This project consists of a series of systematically administered n-of-1 trials among older children to verify the need for ongoing antihypertensive treatment and, if so, to identify the preferred single drug therapy from among the three major classes of drugs commonly used for primary hypertension (angiotensin-converting enzyme inhibitors, calcium channel blockers, and diuretics). We will determine whether one of these is the preferred therapy for the great majority of patients. The "preferred" therapy is the drug which produces normal ambulatory blood pressure, with the greatest reduction in blood pressure without unacceptable side effects. We will recruit 50 patients from the Houston Pediatric and Adolescent Hypertension Program clinic. For each patient, the three drugs will be prescribed in random order and each drug will be taken for 2 weeks. The effectiveness of each therapy will be measured with 24-h ambulatory blood pressure monitoring, and tolerability will be assessed using a side effect questionnaire. Participants will rotate through treatment periods, repeating drugs and adjusting doses until the preferred therapy is identified. In assessing whether one of the medications is most effective for the majority of subjects, the primary outcome will be the percentage of participants for whom each drug is selected as the preferred therapy. We hypothesize that no drug will be selected for the great majority of the subjects, a finding that would support consideration of clinical use of n-of-1 trials. Secondary analyses will explore whether patient characteristics predict which medication will be selected as a preferred drug. DISCUSSION This study will help optimize care of participating patients and provide evidence regarding the usefulness of n-of-1 trials in identifying appropriate treatment for children with hypertension and potentially other disorders. TRIAL REGISTRATION Clinicaltrials.gov NCT02412761 (registered 4/8/2015).
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Affiliation(s)
- Joyce P Samuel
- Division of Pediatric Nephrology and Hypertension, University of Texas Health Science Center at Houston (UTHealth) McGovern Medical School, 6431 Fannin, MSB 3.121, Houston, Texas, 77030, USA.
| | - Joshua A Samuels
- Division of Pediatric Nephrology and Hypertension, University of Texas Health Science Center at Houston (UTHealth) McGovern Medical School, 6431 Fannin, MSB 3.121, Houston, Texas, 77030, USA.
| | | | - Cynthia S Bell
- Division of Pediatric Nephrology and Hypertension, University of Texas Health Science Center at Houston (UTHealth) McGovern Medical School, 6431 Fannin, MSB 3.121, Houston, Texas, 77030, USA.
| | - Claudia Pedroza
- Division of Pediatric Nephrology and Hypertension, University of Texas Health Science Center at Houston (UTHealth) McGovern Medical School, 6431 Fannin, MSB 3.121, Houston, Texas, 77030, USA.
| | - Donald A Molony
- Division of Renal Diseases and Hypertension, UTHealth McGovern Medical School, Houston, Texas, USA.
| | - Jon E Tyson
- Division of Pediatric Nephrology and Hypertension, University of Texas Health Science Center at Houston (UTHealth) McGovern Medical School, 6431 Fannin, MSB 3.121, Houston, Texas, 77030, USA.
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Negroni-Balasquide X, Bell CS, Samuel J, Samuels JA. Is one measurement enough to evaluate blood pressure among adolescents? A blood pressure screening experience in more than 9000 children with a subset comparison of auscultatory to mercury measurements. ACTA ACUST UNITED AC 2015; 10:95-100. [PMID: 26875474 DOI: 10.1016/j.jash.2015.12.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 11/02/2015] [Accepted: 12/01/2015] [Indexed: 02/04/2023]
Abstract
Evaluation of blood pressure is recommended in all children older than 3 years. Auscultatory devices are the recommended method to assess blood pressure in pediatrics, but automated oscillometric devices are increasingly common. A retrospective analysis of our school-based blood pressure screening was performed to determine if multiple oscillometric blood pressure measurements are needed to approach true blood pressure. All children had 4 oscillometric measurements of blood pressures and a random subset of 287 had an additional auscultatory measurement. Among 9870 participants, we observed a nonlinear decrease in blood pressure over time. The largest decrease in systolic blood pressure was between first and second (-3.8 mm Hg) and in diastolic from second to third (-3.3 mm Hg) measurement. For systolic blood pressure, the second oscillometric measurement, the average of second to third and the average of first to third were statistically similar to a single auscultatory measurement. We conclude that assessment of blood pressure using oscillometric devices should include at least 3 measurements in the same sitting to avoid inaccurate assessment.
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Affiliation(s)
- Xamayta Negroni-Balasquide
- Department of Pediatrics, Division of Pediatric Nephrology and Hypertension, University of Texas Health Science Center, Houston, TX, USA.
| | - Cynthia S Bell
- Department of Pediatrics, Division of Pediatric Nephrology and Hypertension, University of Texas Health Science Center, Houston, TX, USA
| | - Joyce Samuel
- Department of Pediatrics, Division of Pediatric Nephrology and Hypertension, University of Texas Health Science Center, Houston, TX, USA
| | - Joshua A Samuels
- Department of Pediatrics, Division of Pediatric Nephrology and Hypertension, University of Texas Health Science Center, Houston, TX, USA
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Campbell JF, Swartz SJ, Wenderfer SE. Nocturnal Hypertension and Attenuated Nocturnal Blood Pressure Dipping is Common in Pediatric Lupus. F1000Res 2015; 4:164. [PMID: 26664705 PMCID: PMC4654458 DOI: 10.12688/f1000research.6532.2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/20/2015] [Indexed: 01/22/2023] Open
Abstract
Hypertension is an important manifestation of systemic lupus erythematosus (SLE) but reports of prevalence vary between 20-70% in published reports of adult and pediatric patients. For both children and adults with SLE, the clinical diagnosis and management of hypertension has traditionally been based on guidelines developed for the general population. In clinical trials, the criteria used for defining participants with hypertension are mostly undefined. As a first step towards formally assessing the blood pressure (BP) patterns of children diagnosed with SLE, 24-hr ambulatory BP monitoring data was analyzed on clinic patients who presented with prehypertension or stage I hypertension. In this pediatric SLE cohort (n=10), 20% met daytime criteria for a diagnosis of hypertension. Patterns of BP elevation varied widely with white coat, masked, isolated systolic, and diastolic nocturnal hypertension all identified. Nocturnal hypertension was detected in 60% and attenuated nocturnal BP dipping in 90% of both hypertensive and normotensive SLE patients. In SLE patients, the median nighttime systolic and diastolic loads were 25% and 15.5% compared with median daily loads of 12.5% and 11.5%. Daytime and nighttime systolic and diastolic BP load and nocturnal dipping was compared to a control population consisting of 85 non-SLE patients under 21 years old with prehypertension or stage 1 hypertension presenting to hypertension clinic. Median systolic BP dipped 5.3 mmHg in SLE patients compared to 11.9 mmHg in non-lupus ( p-value = 0.001). Median diastolic BP dipped 12.9 mmHg versus 18.5 mmHg in non-lupus ( p-value = 0.003). Patterns of BP dysregulation in pediatric SLE merit further exploration. Children with or without SLE displaying prehypertensive or stage 1 casual BP measurements had similar rates of hypertension by ambulatory BP monitoring. However, regardless of BP diagnosis, and independent of kidney involvement, there was an increased proportion with attenuated nocturnal dipping and nocturnal hypertension in SLE patients.
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Affiliation(s)
- J Fallon Campbell
- Department of Pediatrics, Renal Section, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Sarah J Swartz
- Department of Pediatrics, Renal Section, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Scott E Wenderfer
- Department of Pediatrics, Renal Section, Baylor College of Medicine, Houston, TX, 77030, USA
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Screening for hypertension in children and adolescents: the controversy, the research questions and a plan for action. J Hypertens 2015; 33:1359-63. [PMID: 26039528 DOI: 10.1097/hjh.0000000000000629] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Évaluation d’un programme d’enseignement sur la mesure de pression artérielle à domicile chez des enfants suivis en cardio-pédiatrie, une étude quantitative. ACTA ACUST UNITED AC 2015. [DOI: 10.1016/j.refiri.2015.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Out-of-office blood pressure and target organ damage in children and adolescents. J Hypertens 2014; 32:2315-31; discussion 2331. [DOI: 10.1097/hjh.0000000000000384] [Citation(s) in RCA: 96] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Rational use of antihypertensive medications in children. Pediatr Nephrol 2014; 29:979-88. [PMID: 23715784 DOI: 10.1007/s00467-013-2510-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Revised: 04/09/2013] [Accepted: 05/07/2013] [Indexed: 12/13/2022]
Abstract
Hypertension has traditionally been regarded as an uncommon diagnosis in childhood and adolescence; however, there is compelling evidence to suggest that its prevalence is on the rise, particularly in those with obesity. As a result, pediatricians increasingly are asked to evaluate and manage patients with elevated blood pressure. An increased emphasis on conducting drug trials in children over the last 15 years has yielded important advances with respect to evidence-based data regarding the efficacy and safety of antihypertensive medications in children and adolescents. Unfortunately, data to definitively guide selection of initial agents is lacking. This article will present guidelines for the appropriate use of antihypertensive medications in the pediatric population, including the rational approach to selecting an appropriate medication with respect to pathophysiology, putative benefit, and likelihood for side effects.
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Treatment Strategies to Prevent Renal Damage in Hypertensive Children. Curr Hypertens Rep 2014; 16:423. [PMID: 24522942 PMCID: PMC3960483 DOI: 10.1007/s11906-014-0423-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Hypertension secondary to chronic kidney disease prevails in earlier childhood and obesity-related primary hypertension in adolescence. Both are associated with a high risk of renal and cardiovascular morbidity. In children with chronic kidney disease, uncontrolled hypertension may accelerate progression to end-stage renal disease before adulthood is reached and increase a child’s risk of cardiac death a thousand-fold. Obesity-related hypertension is a slow and silent killer, and though early markers of renal damage are recognized during childhood, end-stage renal disease is a risk in later life. Renal damage will be a formidable multiplier of cardiovascular risk for adults in whom obesity and hypertension tracks from childhood. Management options to prevent renal damage will vary for these different target groups. This review provides a summary of the available renoprotective strategies in order to aid physicians involved in the care of this challenging group of children.
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Wightman AG, Oron AP, Symons JM, Flynn JT. Pediatric nephrologists' beliefs regarding randomized controlled trials. J Investig Med 2014; 62:84-7. [PMID: 24379023 DOI: 10.2310/jim.0000000000000019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Pediatrics and pediatric nephrology lag behind adult medicine in producing randomized controlled trials (RCTs). Physician attitudes have been shown to play a significant role in RCT enrollment. METHODS We surveyed members of the American Society of Pediatric Nephrology regarding beliefs about RCTs and factors influencing decisions to recommend RCT enrollment. Regression analyses were used to identify the effects of variables on an aggregate score summarizing attitudes toward RCTs. RESULTS One hundred thirty replies were received. Sixty-six percent had enrolled patients in RCTs. Respondents in practice for more than 15 years were more likely to have recruited a patient to an RCT than those in practice for less than 5 years. Respondents were more willing to recommend RCT enrollment if the study was multicenter, patients were sicker or had a poorer prognosis, or if the parent or participant received a financial incentive versus the provider. In multiple regression analysis, history of enrolling patients in an RCT was the only significant predictor of higher aggregate RCT-friendly attitude. CONCLUSIONS Many pediatric nephrologists have never enrolled a patient in an RCT, particularly those in practice for less than 5 years. Respondents who have not enrolled patients in RCTs have a less RCT-friendly attitude. Provision of improved training and resources might increase participation of junior providers in RCTs.
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Affiliation(s)
- Aaron G Wightman
- From the *Division of Nephrology, Department of Pediatrics, University of Washington School of Medicine; †Division of Nephrology, Seattle Children's Hospital; and ‡Core for Biomedical Statistics, Seattle Children's Hospital, Seattle, WA
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Flynn JT. Assessment of Blood Pressure in Children: It's All in the Details. J Clin Hypertens (Greenwich) 2013; 15:772-3. [DOI: 10.1111/jch.12192] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Joseph T. Flynn
- Department of Pediatrics, University of Washington and Division of Nephrology; Seattle Children's Hospital; Seattle WA
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Lande MB, Adams HR, Kupferman JC, Hooper SR, Szilagyi PG, Batisky DL. A multicenter study of neurocognition in children with hypertension: methods, challenges, and solutions. ACTA ACUST UNITED AC 2013; 7:353-62. [PMID: 23792121 DOI: 10.1016/j.jash.2013.05.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Revised: 04/24/2013] [Accepted: 05/08/2013] [Indexed: 11/17/2022]
Abstract
Hypertensive adults demonstrate decreased performance on neurocognitive testing compared with that of normotensive controls. There is now emerging, preliminary evidence that children with hypertension also manifest neurocognitive differences when compared with normotensive controls, findings postulated to potentially represent early signs of hypertensive target organ damage to the brain. However, reports in children to date have been limited to database and single-center studies. We have established an ongoing, prospective, multicenter study of neurocognition in children with primary hypertension. This article outlines the study methods, with particular attention to the unique challenges in this area of clinical research. We highlight aspects of the study design that are specifically designed as solutions to these challenges.
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Affiliation(s)
- Marc B Lande
- Department of Pediatrics, University of Rochester, Rochester, NY.
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Taler SJ, Agarwal R, Bakris GL, Flynn JT, Nilsson PM, Rahman M, Sanders PW, Textor SC, Weir MR, Townsend RR. KDOQI US commentary on the 2012 KDIGO clinical practice guideline for management of blood pressure in CKD. Am J Kidney Dis 2013; 62:201-13. [PMID: 23684145 DOI: 10.1053/j.ajkd.2013.03.018] [Citation(s) in RCA: 138] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Accepted: 03/27/2013] [Indexed: 01/13/2023]
Abstract
In response to the 2012 KDIGO (Kidney Disease: Improving Global Outcomes) guideline for blood pressure management in patients with chronic kidney disease not on dialysis, the National Kidney Foundation organized a group of US experts in hypertension and transplant nephrology to review the recommendations and comment on their relevancy in the context of current US clinical practice and concerns. The overriding message was the dearth of clinical trial evidence to provide strong evidence-based recommendations. For patients with CKD with normal to mildly increased albuminuria, goal blood pressure has been relaxed to ≤140/90 mm Hg for both diabetic and nondiabetic patients. In contrast, KDIGO continues to recommend goal blood pressure ≤130/80 mm Hg for patients with chronic kidney disease with moderately or severely increased albuminuria and for all renal transplant recipients regardless of the presence of proteinuria, without supporting data. The expert panel thought the KDIGO recommendations were generally reasonable but lacking in sufficient evidence support and that additional studies are greatly needed.
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Affiliation(s)
- Sandra J Taler
- Division of Nephrology and Hypertension, College of Medicine, Mayo Clinic, Rochester, MN, USA
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Batisky DL. What is the optimal first-line agent in children requiring antihypertensive medication? Curr Hypertens Rep 2013; 14:603-7. [PMID: 22986908 DOI: 10.1007/s11906-012-0302-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
There has been an evolution in the understanding of the treatment of hypertension in children and adolescents over the past decade. This has been fueled in part by the increased attention paid to the clinical problem, given the increasing numbers of children and adolescents being diagnosed with this condition. There has also been a growing number of clinical trials performed and completed that demonstrate the blood pressure (BP)-lowering effects of antihypertensives and the side effect profiles of these medications, and that has led to FDA-labeling of many antihypertensive medications for use in children and adolescents. However, none of these trials has provided definitive data on the optimal first line agent for this patient population. Clinical experience and other approaches discussed in this review are still necessary to guide treatment of hypertension in the young. The quest for the optimal antihypertensive agent is just beginning, and it is going to take some extraordinary effort to reach that goal.
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Affiliation(s)
- Donald L Batisky
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA.
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Karpettas N, Nasothimiou E, Kollias A, Vazeou A, Stergiou GS. Ambulatory and home blood pressure monitoring in children and adolescents: diagnosis of hypertension and assessment of target-organ damage. Hypertens Res 2013; 36:285-92. [PMID: 23344131 DOI: 10.1038/hr.2012.220] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The prevalence of elevated blood pressure in children and adolescents is more common than previously believed and often represents the early onset of essential hypertension, particularly in adolescents. The definition of hypertension in children is based on distribution criteria and normalcy tables that provide blood pressure percentiles for each measurement method (office, ambulatory and home) according to the individual's age, gender and body size. Owing to the white coat and masked hypertension phenomena, ambulatory blood pressure monitoring is indispensable for the diagnosis of hypertension in children. Home blood pressure monitoring in children has been less well studied, and at present, treatment decisions should not be based solely on such measurements. Hypertension-induced preclinical target-organ damage (mainly echocardiographic left ventricular hypertrophy) is not uncommon in children and should be evaluated in all hypertensive children. Other indices of target-organ damage, such as carotid intima-media thickness, pulse wave velocity and microalbuminuria, remain under investigation in pediatric hypertension.
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Affiliation(s)
- Nikos Karpettas
- Hypertension Center, Third University Department of Medicine, Sotiria Hospital, Athens, Greece
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Flynn JT, Urbina EM. Pediatric ambulatory blood pressure monitoring: indications and interpretations. J Clin Hypertens (Greenwich) 2012; 14:372-82. [PMID: 22672091 DOI: 10.1111/j.1751-7176.2012.00655.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The prevalence of hypertension in children and adolescents is increasing, especially in obese and ethnic children. The adverse long-term effects of hypertension beginning in youth are known; therefore, it is important to identify young patients who need intervention. Unfortunately, measuring blood pressure (BP) is difficult due to the variety of techniques available and innate biologic variation in BP levels. Ambulatory BP monitoring may overcome some of the challenges clinicians face when attempting to categorize a young patient's BP levels. In this article, the authors review the use of ambulatory BP monitoring in pediatrics, discuss interpretation of ambulatory BP monitoring, and discuss gaps in knowledge in usage of this technique in the management of pediatric hypertension.
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Affiliation(s)
- Joseph T Flynn
- Division of Nephrology, Seattle Children's Hospital, Seattle, WA 98105, USA.
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Efficacy and safety of valsartan compared to enalapril in hypertensive children: a 12-week, randomized, double-blind, parallel-group study. J Hypertens 2012; 29:2484-90. [PMID: 22025233 DOI: 10.1097/hjh.0b013e32834c625c] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This study compares efficacy and safety of valsartan with enalapril in hypertensive children aged 6-17 years. METHOD This was a 12-week, randomized, double-blind, parallel-group, active-controlled study. After a single-blind placebo run-in period (4-28 days), patients with mean sitting systolic blood pressure (BP) (MSSBP) at least 95th percentile for age, gender, and height were randomized to receive half the assigned dose for first week, and force-titrated to full dose for 11 weeks (≥18 to <35 kg - valsartan: 80 mg, enalapril: 10 mg; ≥35 to <80 kg - valsartan: 160 mg, enalapril: 20 mg; ≥80 to ≤160 kg - valsartan: 320 mg, enalapril: 40 mg). The primary efficacy variable was changed from baseline in MSSBP to show noninferiority of valsartan to enalapril. Other efficacy variables were changed from baseline in MSDBP, SBP control rate, and 24-h ambulatory BP parameters. RESULTS Of 300 randomized patients, 281 (94%) completed the study. At week 12, MSSBP reductions were similar for valsartan and enalapril (primary endpoint of noninferiority, P < 0.0001). Least square mean BP reductions from baseline of -15.4/-9.4 mmHg were observed for valsartan compared with -14.1/-8.5 mmHg for enalapril. A similar proportion of patients achieved SBP control (valsartan: 67%; enalapril: 70%). In the subset of patients who underwent ambulatory BP assessments, valsartan provided greater reductions than enalapril in mean 24-h SBP (valsartan: -9.8 mmHg, enalapril: -7.2 mmHg: P = 0.03). The overall incidence of AEs was similar (valsartan 60%, enalapril 58%) with headache, cough, and nasopharyngitis reported most frequently. CONCLUSIONS Valsartan and enalapril provided comparable BP reductions and effective BP control and were well tolerated in hypertensive children aged 6-17 years.
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Flynn JT, Pierce CB, Miller ER, Charleston J, Samuels JA, Kupferman J, Furth SL, Warady BA. Reliability of resting blood pressure measurement and classification using an oscillometric device in children with chronic kidney disease. J Pediatr 2012; 160:434-440.e1. [PMID: 22048052 PMCID: PMC3274610 DOI: 10.1016/j.jpeds.2011.08.071] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2011] [Revised: 07/18/2011] [Accepted: 08/31/2011] [Indexed: 10/15/2022]
Abstract
OBJECTIVE To compare the reliability of blood pressure (BP) readings obtained with an oscillometric device with those obtained by auscultation and assess for differences in BP status classification based on the 2 techniques. STUDY DESIGN Resting BP was measured by auscultation and with an oscillometric device at the same encounter in 235 subjects enrolled in the Chronic Kidney Disease in Children study. Resting auscultatory BP values were averaged and compared with averaged oscillometric readings. BP agreement by the 2 methods was assessed using Bland-Altman plots, and BP status classification agreement was assessed by calculation of kappa statistics. RESULTS Oscillometric BP readings were higher than auscultatory readings, with a median paired difference of 9 mm Hg for systolic BP (SBP) and 6 mm Hg for diastolic BP (DBP). Correlation for mean SBP was 0.624 and for mean DBP was 0.491. The bias for oscillometric BP measurement was 8.7 mm Hg for SBP (P < .01) and 5.7 mm Hg for DBP (P < .01). BP status classification agreement was 61% for SBP and 63% for DBP, with Kappa values of .31 for SBP and .20 for DBP. CONCLUSIONS Compared with auscultation, the oscillometric device significantly overestimated both SBP and DBP, leading to frequent misclassification of BP status.
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Affiliation(s)
| | | | | | - Jeanne Charleston
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | | | | | - Susan L Furth
- Children’s Hospital of Philadelphia, Philadelphia, PA
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McBryde KD. Blood pressure in pediatric chronic kidney disease--it's in the ears of the beholder. J Pediatr 2012; 160:363-5. [PMID: 22082951 DOI: 10.1016/j.jpeds.2011.10.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2011] [Accepted: 10/05/2011] [Indexed: 11/24/2022]
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Abstract
Traditionally, antihypertensive medications were used in few children or adolescents, usually just those with underlying renal or other organ system disease. However, with recent data suggesting that the incidence of primary hypertension may be increasing in the young, it is possible that more children and adolescents will be prescribed antihypertensive agents. This article will review currently available pediatric data on the use of calcium channel blockers, agents affecting the renin-angiotensin-aldosterone system and other classes of antihypertensive medications in children, highlighting appropriate indications and safety considerations. Guidelines for use of antihypertensive medications, including choice of initial agent and how to prescribe appropriately, will be presented.
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Flynn JT. Ambulatory blood pressure monitoring in children: imperfect yet essential. Pediatr Nephrol 2011; 26:2089-94. [PMID: 21866381 DOI: 10.1007/s00467-011-1984-9] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2011] [Accepted: 07/21/2011] [Indexed: 11/28/2022]
Abstract
There has been increasing emphasis on hypertension and early cardiovascular disease in the pediatric age group over the past decade as a result of various factors, including the obesity epidemic and publication of new clinical guidelines. A key component of identifying children and adolescents with definite or potential hypertension is proper blood pressure (BP) measurement. While ambulatory blood pressure monitoring (ABPM) offers the potential for improved detection of youths at increased cardiovascular risk, it has not been widely adopted. This commentary highlights the crucial role of ABPM in the context of current trends, while at the same time identifying the current barriers to more widespread application of this technique. Chief among these is the lack of a robust, universally applicable database of pediatric ABPM normative values. Even in the absence of ideal normative data, ABPM can and should be widely applied, and a potential algorithm for such an approach is presented.
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Affiliation(s)
- Joseph T Flynn
- University of Washington School of Medicine, Seattle, WA, USA,
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Karpettas N, Kollias A, Vazeou A, Stergiou GS. Office, ambulatory and home blood pressure measurement in children and adolescents. Expert Rev Cardiovasc Ther 2011; 8:1567-78. [PMID: 21090932 DOI: 10.1586/erc.10.148] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
There is an increasing interest in pediatric hypertension, the prevalence of which is rising in parallel with the obesity epidemic. Traditionally the assessment of hypertension in children has relied on office blood pressure (BP) measurements by the physician. However, as in adults, office BP might be misleading in children mainly due to the white coat and masked hypertension phenomena. Thus, out-of-office BP assessment, using ambulatory or home monitoring, has gained ground for the accurate diagnosis of hypertension and decision-making. Ambulatory monitoring is regarded as indispensable for the evaluation of pediatric hypertension. Preliminary data support the usefulness of home monitoring, yet more evidence is needed. Office, ambulatory and home BP normalcy tables providing thresholds for diagnosis have been published and should be used for the assessment of elevated BP in children.
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Affiliation(s)
- Nikos Karpettas
- Hypertension Center, Third University Department of Medicine, Sotiria Hospital, 152 Mesogion Avenue, Athens 11527, Greece
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Sinha R, Dionne J. Ambulatory blood pressure monitoring in children. Indian Pediatr 2011; 48:119-22. [DOI: 10.1007/s13312-011-0042-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Comparison of office, ambulatory and home blood pressure in children and adolescents on the basis of normalcy tables. J Hum Hypertens 2010; 25:218-23. [DOI: 10.1038/jhh.2010.59] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Yim HE, Lee EH, Jang GY, Yoo KH, Son CS, Hong YS, Lee JW, Ito Y, Ikezumi Y, Uchiyama M. Questionnaire survey on pediatric hypertension in Japan and Korea. Pediatr Int 2010; 52:1-5. [PMID: 19419516 DOI: 10.1111/j.1442-200x.2009.02860.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Hypertension (HTN) is no longer viewed as an adult disease. The purpose of the present study was to understand how hypertensive children are evaluated and managed, by surveying pediatricians in Japan and South Korea. METHODS A questionnaire was mailed to 109 Japanese (JA) and 159 Korean (KO) pediatric cardiologists, pediatric nephrologists, and other pediatricians. RESULTS A total of 127 replies were received (response rate 47%). Most of respondents did not check blood pressure (BP) routinely in outpatient clinics (JA 77%, KO 88%). A mercury sphygmomanometer was the most commonly used method for BP measurements (JA 72%, KO 62%). BP treatment goals were usually set at the 95th percentile for age, gender, and height (JA 47%, KO 54%). More KO used a lower goal in children with primary HTN than JA. KO respondents preferred angiotensin-converting enzyme inhibitors (ACEI) as initial agents regardless of underlying diseases whereas JA respondents chose various medications, that is, calcium channel blockers, diuretics, and ACEI. For BP monitoring, self-monitoring was found to be most frequent in both countries (JA 80%, KO 57%). Ambulatory BP monitoring was not frequently utilized in both countries (JA 33% KO 34%). CONCLUSION The current assessment, management and differing trends in pediatric HTN in Japan and Korea have been identified in the present study. Pediatricians should be aware of the growing implications of HTN in children.
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Affiliation(s)
- Hyung Eun Yim
- Department of Pediatrics, Korea University, Seoul, Korea
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Kapur G, Ahmed M, Pan C, Mitsnefes M, Chiang M, Mattoo TK. Secondary Hypertension in Overweight and Stage 1 Hypertensive Children: A Midwest Pediatric Nephrology Consortium Report. J Clin Hypertens (Greenwich) 2010; 12:34-9. [DOI: 10.1111/j.1751-7176.2009.00195.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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DiPietro A, Kees-Folts D, DesHarnais S, Camacho F, Wassner SJ. Primary hypertension at a single center: treatment, time to control, and extended follow-up. Pediatr Nephrol 2009; 24:2421-8. [PMID: 19714367 DOI: 10.1007/s00467-009-1297-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2009] [Revised: 07/26/2009] [Accepted: 07/28/2009] [Indexed: 01/20/2023]
Abstract
We present data on presentation, treatment, and follow-up of 65 pediatric patients with primary hypertension treated over the past 12 years, including initial anthropometric data, pharmacologic treatment, time to control for both systolic and diastolic blood pressure (SBP/DBP), and maintenance of control over time. Data was normalized to standard deviation scores (SDS) for mathematical analysis, and antihypertensive medication dosages were converted to dosage equivalents for a single member of each antihypertensive class. We used multiple regression analysis and Kaplan- Meier survival curves to determine the time to control, medication, and dose effectiveness. Patients were seen for an average of seven visits over 25 months. Initial BPs averaged 134/71 mmHg (2.1/0.6 SDS). Patients were taller, heavier, and had higher body mass index than average for age and sex. By the fourth visit, SBP was <90th percentile in 79%. Ninety percent could be controlled, although 32 lost control at some point (at least 16 due to noncompliance). At the last visit, 46 were controlled, and 5/8 patients off medication remained normotensive. Only angiotensin-converting enzyme inhibitors and beta-blockers demonstrated significant association with BP control. This is the first study to document the time to control of BP, and it can serve as an initial standard for quality assessment.
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Affiliation(s)
- Amy DiPietro
- Department of Pediatrics, The Penn State College of Medicine, The Milton S. Hershey Medical Center, PO Box 850, Hershey, PA 17033, USA
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