Left ventricular hypertrophy and arterial wall thickening in children with essential hypertension

Etiology and Medication of Hospitalized Children With Hypertension: A Retrospective Study

With the increasing incidence of hypertension in children, the lack of high-quality research data on antihypertensive drugs in pediatric patients restricts treatment options for clinicians and can lead to suboptimal outcomes. We conducted a retrospective analysis of clinical data from hospitalized pediatric patients diagnosed with hypertension and treated with antihypertensive drugs in the past 3 years. The study included 203 pediatric patients (119 males and 84 females), with an average age of 8.9 ± 4.7 years (range: 0.1-17 years). Clinical symptoms of hypertension were observed in 132 participants (65.0%), and the conditions in all cases were classified as primary or secondary hypertension. Renal causes (71 patients, 35.0%) and drug-induced factors (39 patients, 19.2%) were the main causes of secondary hypertension. Nifedipine (137 patients, 67.5%) was the most commonly prescribed medication, followed by captopril (84 patients, 41.4%). Multiple antihypertensive medications were prescribed to 99 participants (48.8%), and blood pressure returned to normal in 111 patients (54.7%). Hypertension-related organ damage was observed in 47 patients (23.2%). Timely diagnosis and treatment of hypertension are critical to prevent organ damage in pediatric patients. Although nifedipine was widely used in this pediatric cohort, the appropriateness of this treatment remains unclear. Emphasis should be placed on monitoring target organs affected by pediatric hypertension, and post-discharge antihypertensive treatment should include thorough follow-ups and documentation.

The association of blood pressure, body mass index and carotid intima-media thickness as childhood predictors of cardiovascular disease risk: A systematic review and meta-analysis

Background and Aims

Blood pressure, body mass index (BMI), and carotid intima-media thickness (CIMT) are well-known independent predictors of cardiovascular disease especially in adulthood. However, there is insufficient evidence regarding the statistical significance of the relationship between childhood CIMT, blood pressure and BMI. This systematic review and meta-analysis was therefore conducted to ascertain the relationship.

Methods

This systematic review and meta-analysis was reported in accordance with the PRISMA statement. Three electronic databases were searched, namely EMBASE, MEDLINE and the Cochrane Library. Data were extracted independently by two review authors. Quantitative data were analyzed using Review Manager.

Results

The meta-analysis was conducted using a random effects model and standard mean difference. The results of the meta-analysis indicated a statistically significant difference in CIMT of 0.86 (95% CI: 0.41-1.31) between normotensive versus hypertensive children. Again, overweight and moderately obese children had higher CIMT values as compared to normal weight children with a pooled standard mean difference of 0.72 (95% CI: 0.24-1.20) and 2.75 (95% CI: 0.73-4.77) respectively. The pooled standard mean difference of systolic and diastolic blood pressures was found to be 2.44 (95% CI: 1.69-3.19) and 1.28 (95% CI: 0.65-1.92) respectively between normal weight and overweight/obese children.

Conclusion

The meta-analysis found a significant difference in CIMT between normotensive and hypertensive children, with overweight and moderately obese children having higher CIMT values. Thus, conducting CIMT screening for obese or overweight children and children with increased blood pressure can provide valuable information about their cardiovascular disease risk.

Soluble epoxide hydrolase and TRPC3 channels jointly contribute to homocysteine-induced cardiac hypertrophy: Interrelation and regulation by C/EBPβ

OBJECTIVES

Studies in certain cardiac hypertrophy models suggested the individual role of soluble epoxide hydrolase (sEH) and canonical transient receptor potential 3 (TRPC3) channels, however, whether they jointly mediate hypertrophic process remains unexplored. Hyperhomocysteinemia promotes cardiac hypertrophy while the involvement of sEH and TRPC3 channels remains unknown. This study aimed to explore the role of, and interrelation between sEH and TRPC3 channels in homocysteine-induced cardiac hypertrophy.

METHODS

Rats were fed methionine-enriched diet to induce hyperhomocysteinemia. H9c2 cells and neonatal rat cardiomyocytes were incubated with homocysteine. Cardiac hypertrophy was evaluated by echocardiography, histological examination, immunofluorescence imaging, and expressions of hypertrophic markers. Epoxyeicosatrienoic acids (EETs) were determined by ELISA. TRPC3 current was recorded by patch-clamp. Gene promotor activity was measured using dual-luciferase reporter assay.

RESULTS

Inhibition of sEH by 1-trifluoromethoxyphenyl-3-(1-propionylpiperidin-4-yl) urea (TPPU) reduced ventricular mass, lowered the expression of hypertrophic markers, decreased interstitial collagen deposition, and improved cardiac function in hyperhomocysteinemic rats, associated with restoration of EETs levels in myocardium. TPPU or knockdown of sEH suppressed TRPC3 transcription and translation as well as TRPC3 current that were enhanced by homocysteine. Exogenous 11,12-EET inhibited homocysteine-induced TRPC3 expression and cellular hypertrophy. Silencing C/EBPβ attenuated, while overexpressing C/EBPβ promoted homocysteine-induced hypertrophy and expressions of sEH and TRPC3, resulting respectively from inhibition or activation of sEH and TRPC3 gene promoters.

CONCLUSIONS

sEH and TRPC3 channels jointly contribute to homocysteine-induced cardiac hypertrophy. Homocysteine transcriptionally activates sEH and TRPC3 genes through a common regulatory element C/EBPβ. sEH activation leads to an upregulation of TRPC3 channels via a 11,12-EET-dependent manner.

Systolic and diastolic left ventricular function in children with primary hypertension: a systematic review and meta-analysis

OBJECTIVE

Evaluation of left ventricular function provides early evidence of target-organ damage in children with primary hypertension. We performed a systematic review and meta-analysis of left ventricular systolic and diastolic function in children and adolescents with primary hypertension.

METHODS

Literature search was performed in PubMed database and out of 718 articles (published between 2000 and 2021) 22 studies providing comparison of left ventricular function parameters between children with primary hypertension and normotensive controls were selected.

RESULTS

Overall, 3460 children (5-21 years) with primary hypertension were analyzed. Meta-analysis showed that hypertensive patients when compared with normotensives, had an increased heart rate (mean difference [MD] 5.59; 95% confidence interval [CI] 3.28, 7.89; 10 studies) and increased fractional shortening (MD 1.04; 95% CI 0.48, 1.60; 9 studies) but did not differ in ejection fraction (MD -0.03; 95% CI -1.07, 1.02; 12 studies). Stroke volume was higher in one out of three studies, whereas no differences in cardiac output were found in two studies with available data. Hypertensive children had also lower E/A values (MD -0.21; -0.33, -0.09; 14 studies), greater values of E/e' (MD 0.59; 0.36, 0.82; 8 studies) and greater global longitudinal stress (MD 2.50; 2.03, 2.96; 4 studies) when compared to those with normotension.

CONCLUSION

Our results indicate that hypertensive children and adolescents present with signs of hyperkinetic function of the left ventricle, demonstrate evidence of increased left ventricular strain and impaired diastolic function compared to normotensive controls.

Accelerated vascular age in adolescents with primary hypertension

BACKGROUND

Primary hypertension may lead to early vascular ageing. We aimed to evaluate differences between expected vascular age based on pulse wave velocity (PWV)/carotid intima-media thickness (cIMT) and actual chronological age (CHA) in adolescents with primary hypertension.

METHODS

Three hundred and fifty-two children (median age of 15.5 years) with office hypertension and 64 normotensive healthy children of the same age underwent anthropometry, office and ambulatory blood pressure (BP), left ventricular mass index, cIMT, PWV, pulse wave analysis and biochemistry measurements. Vascular age was calculated using pooled pediatric and adult normative PWV and cIMT data. The difference between vascular age and CHA was calculated in relation to the 90th percentile for PWV (PWVAgeDiff90) and the 95th percentile for cIMT (cIMTAgeDiff95).

RESULTS

One hundred and sixty-six patients had white-coat hypertension (WCH), 32 had ambulatory prehypertension (AmbPreHT), 55 had isolated systolic hypertension with normal central SBP (ISH+cSBPn), 99 had elevated office, ambulatory and cSBP (true hypertension, tHT). The differences between vascular age (both PWV and cIMT based) and CHA were significantly higher in AmbPreHT and tHT compared with normotension, WCH and ISH+cSBPn. Median PWVAgeDidff90 was -3.2, -1.2, -2.1, +0.8 and +0.3 years in normotension, WCH, ISH+cSBPn, AmbPreHT and tHT, respectively. Median cIMTAgeDiff95 was -8.0, -6.3, -6.8, -3.8 and -4.3 years in normotension, WCH, ISH+cSBPn, AmbPreHT and tHT, respectively. Significant predictors of PWVAge90Diff were the DBP and serum cholesterol, whereas cSBP and augmentation index were significant predictors of cIMTAgeDiff95.

CONCLUSION

Children with AmbPreHT and tHT show accelerated vascular age compared with their normotensive peers.

Prediction of the hypertension risk in teenagers

BACKGROUND

Creation of a hypertension risk stratification model and development of an algorithm to detect hypertension in teenagers.

METHODS

The study group consisted of 690 middle and high school students, aged 15-17 years, from the metropolitan area of Warsaw, Poland. Information concerning family history and presence of risk factors for cardiovascular disease was gathered. Three-time blood pressure measurements were taken during at least two separate visits, which were at least a week apart, using the auscultatory method, according to standard procedures. Anthropometric measurements included: body weight, height, arm, hip and abdominal circumference, skin-fold thickness measured on the rear surface of an arm, below the inferior angle of the scapula and at the belly. Following indexes were determined: body mass index, waist to hip ratio (WHR), waist to height ratio, hip to height ratio.

RESULTS

A logistic regression model, describing the risk of hypertension in adolescents aged 15-17 was invented. p(x) = (e^g(x))/(1+e^g(x)) where ĝ(x) = -0.097 × height+0.085 × weight+7.764 × WHR+1.312 × family hypertension. Family hypertension means presence of hypertension among members of the closest family. The formula was created, allowing the pre-selection of adolescents at risk of hypertension during screening. Next an algorithm for the detection of hypertension for practical use was proposed.

CONCLUSIONS

Body weight, WHR and incidence of hypertension in the family are the strongest predictors of hypertension in teenagers. Proposed screening algorithm can be a useful tool for selecting teenagers at risk of hypertension and in need of specialized diagnostics and care.

The enigma of primary hypertension in childhood

Beginning in the 1970s, hypertension in children and adolescents has been defined as systolic and/or diastolic blood pressure (BP) that is equal to or greater than the 95th percentile of the normal BP distribution in healthy children. The definition of hypertension in adults is based on longitudinal data that links a BP level with an increased risk for subsequent adverse outcomes related to hypertension including heart failure, kidney failure, stroke, or death. The statistical definition of hypertension continues to be used in childhood because there have been no data that link a BP level in childhood with a heightened risk for adverse outcomes in adulthood. Findings from clinical and epidemiologic research have advanced understanding of high BP in childhood. While hypertension in some children can be secondary to underlying kidney, cardiovascular, or endocrine disorder, it is now known that primary (essential) hypertension can be present in childhood. The prevalence of hypertension in childhood is approximately 2–5% and another 13–18% of children and adolescents have elevated BP and are at heightened risk for developing hypertension. The leading cause of childhood hypertension is primary hypertension, especially in adolescents. For children and adolescents with secondary hypertension, the treatment can focus on managing the underlying cause of hypertension. Less is known about managing primary hypertension in childhood, including diagnosis, evaluation, treatment, and possibilities for prevention. The phenotype of primary hypertension in childhood and recent findings will be discussed.

Prevalence of left ventricular hypertrophy in children and young people with primary hypertension: Meta-analysis and meta-regression

BACKGROUND

Left ventricular hypertrophy (LVH) is the main marker of HMOD in children and young people (CYP). We aimed to assess the prevalence of LVH and its determinants in CYP with primary hypertension (PH).

METHODS

A meta-analysis of prevalence was performed. A literature search of articles reporting LVH in CYP with PH was conducted in Medline, Embase, and Cochrane databases. Studies with a primary focus on CYP (up to 21 years) with PH were included. Meta-regression was used to analyze factors explaining observed heterogeneity.

RESULTS

The search yielded a total of 2,200 articles, 153 of those underwent full-text review, and 47 reports were included. The reports evaluated 51 study cohorts including 5,622 individuals, 73% male subjects, and a mean age of 13.6 years. LVH was defined as left ventricle mass index (LVMI) ≥ 95th percentile in 22 (47%), fixed cut-off ≥38.6 g/m2.7 in eight (17%), sex-specific fixed cut-off values in six (13%), and miscellaneously in others. The overall prevalence of LVH was 30.5% (95% CI 27.2-33.9), while heterogeneity was high (I 2 = 84%). Subgroup analysis including 1,393 individuals (76% male subjects, mean age 14.7 years) from pediatric hypertension specialty clinics and LVH defined as LVMI ≥95th percentile only (19 study cohorts from 18 studies), reported prevalence of LVH at 29.9% (95% CI 23.9 to 36.3), and high heterogeneity (I 2 = 84%). Two studies involving patients identified through community screening (n = 1,234) reported lower LVH prevalence (21.5%). In the meta-regression, only body mass index (BMI) z-score was significantly associated with LVH prevalence (estimate 0.23, 95% CI 0.08-0.39, p = 0.004) and accounted for 41% of observed heterogeneity, but not age, male percentage, BMI, or waist circumference z-score. The predominant LVH phenotype was eccentric LVH in patients from specialty clinics (prevalence of 22% in seven studies with 779 participants) and one community screening study reported the predominance of concentric LVH (12%).

CONCLUSION

Left ventricular hypertrophy is evident in at least one-fifth of children and young adults with PH and in nearly a third of those referred to specialty clinics with a predominant eccentric LVH pattern in the latter. Increased BMI is the most significant risk association for LVH in hypertensive youth.

Multi-centre cross-sectional study on vascular remodelling in children following successful coarctation correction

Coarctation of the aorta is an arteriopathy with life-long sequelae, with remarkably increased cardiovascular events in young adults even after successful repair and despite blood pressure status. There are data on arterial remodelling in adults after coarctation correction, however, these data are scarce in childhood. Thus, the aim of this cross-sectional study was to evaluate changes in arterial wall function and morphology in children following successful coarctation repair and to compare these changes among patients with different blood pressure status and coarctation correction modes. Blood pressure status, echocardiographic parameters, arterial wall structure and stiffness, endothelial function and central blood pressure measurements were evaluated in 110 children aged 6-18 years following successful coarctation repair with right arm blood pressure not exceeding leg blood pressure by ≥20 mmHg. The prevalence of arterial hypertension was 50%. The mean carotid intima-media thickness SDS was 3.1 ± 1.5 and above 1.65 SDS in 91 of 110 patients. Increased right carotid intima-media thickness was associated with left ventricular hypertrophy, office blood pressure difference between leg and right arm, recoarctation in the past and interventional coarctation correction. Increased local common carotid artery stiffness was associated with increased pulse pressure and central systolic blood pressure. Potentially decreased endothelial function was related to a slight increase of peak and mean systolic gradient in the descending aorta. After successful coarctation repair and with a low blood pressure gradient, children still have a high prevalence of arterial hypertension and significant arterial remodelling, indicating accelerated biological age and advanced arteriosclerosis.

Hypertension and Associated Risk Factors among Children with Intellectual Disability: A Cross-Sectional Study

To investigate the prevalence of hypertension and associated risk factors in Chinese children with intellectual disability, a cross-sectional study was conducted in a sample of 558 children with intellectual disability aged 6–18 years in Hong Kong, and 452 (81.0%) with valid data were included in the data analysis. Blood pressure was measured according to a standard protocol. Hypertension was defined using the age-, gender-, and height-specific classification criteria recommended by the 2018 Chinese Guidelines for Children. Multivariate and hierarchical logistic regression was fitted to examine the associations of hypertension with potential risk factors. Overall, 31.4% of the participants were classified as having hypertension. Obese children were more likely to develop hypertension than non-obese children (adjusted OR = 2.77, 95% CI: 1.28, 5.99, p = 0.010). A paternal education of college or above and a paternal occupation of clerks, sales representatives, and workers were also associated with an increased risk of hypertension. The prevalence of hypertension is high among Chinese children with intellectual disability. Obesity was the strongest risk factor. Further longitudinal studies are warranted to confirm our findings. Nevertheless, preventions against obesity are promising to receive doubled benefits in reducing both obesity and hypertension, given its strong relationship with hypertension in this special population.

Disparities between determinants of impaired vascular structure and function in young people with primary hypertension: a systematic review

OBJECTIVE

Early effects of primary hypertension on arterial structure and function in children and young people (CYP) and their determinants remain elusive. We aimed to review independent determinants of carotid intima-media thickness (cIMT), carotid wall cross-sectional area (WCSA) and carotid-femoral pulse wave velocity (cfPWV) in CYP with primary hypertension.

METHODS

We performed a systematic review of studies reporting multivariable analysis of cfPWV, cIMT and WCSA in CYP (up to 25 years of age) with primary hypertension. Literature search was performed in PubMed database and 13, 12 and two articles including 3860 (age range 4-25 years, 50% male individuals), 2038 children (5-25 years, 55% male individuals) and 136 children (5-17 years, 85% male individuals) were selected for final analysis of cfPWV, cIMT and WCSA, respectively.

RESULTS

Ninety and 86% of the studies reported higher cfPWV and cIMT in CYP with elevated blood pressure (BP) compared with normotensive controls. Different indices of BP were positively associated with cfPWV in 92% of studies, whereas BMI showed association in 31%. Carotid IMT associated with BP indices in 50% and with BMI in 25% of the studies. WCSA was studied longitudinally and its improvement associated with decrease in measures of central obesity.

CONCLUSION

We found a disparity between the determinants of structural and functional impairment of arterial tree in CYP with primary hypertension. In contrast to cIMT and WCSA, increase of cfPWV is almost exclusively determined by BP.

Endoplasmic reticulum stress mediates homocysteine-induced hypertrophy of cardiac cells through activation of cyclic nucleotide phosphodiesterase 1C

Although the association of elevated homocysteine level with cardiac hypertrophy has been reported, the molecular mechanisms by which homocysteine induces cardiac hypertrophy remain inadequately understood. In this study we aim to uncover the roles of cyclic nucleotide phosphodiesterase 1 (PDE1) and endoplasmic reticulum (ER) stress and their relationship to advance the mechanistic understanding of homocysteine-induced cardiac cell hypertrophy. H9c2 cells and primary neonatal rat cardiomyocytes are exposed to homocysteine with or without ER stress inhibitor TUDCA or PDE1-specific inhibitor Lu AF58027, or transfected with siRNAs targeting PDE1 isoforms prior to homocysteine-exposure. Cell surface area is measured and ultrastructure is examined by transmission electron microscopy. Hypertrophic markers, PDE1 isoforms, and ER stress molecules are detected by q-PCR and western blot analysis. Intracellular cGMP and cAMP are measured by ELISA. The results show that homocysteine causes the enlargement of H9c2 cells, increases the expressions of hypertrophic markers β-MHC and ANP, upregulates PDE1A and PDE1C, promotes the expressions of ER stress molecules, and causes ER dilatation and degranulation. TUDCA and Lu AF58027 downregulate β-MHC and ANP, and alleviate cell enlargement. TUDCA decreases PDE1A and PDE1C levels. Silencing of PDE1C inhibits homocysteine-induced hypertrophy, whereas PDE1A knockdown has minor effect. Both cAMP and cGMP are decreased after homocysteine-exposure, while only cAMP is restored by Lu AF58027 and TUDCA. TUDCA and Lu AF58027 also inhibit cell enlargement, downregulate ANP, β-MHC and PDE1C, and enhance cAMP level in homocysteine-exposed primary cardiomyocytes. ER stress mediates homocysteine-induced hypertrophy of cardiac cells via upregulating PDE1C expression Cyclic nucleotide, especially cAMP, is the downstream mediator of the ER stress-PDE1C signaling axis in homocysteine-induced cell hypertrophy.

Approach to Hypertension in Adolescents and Young Adults

PURPOSE OF REVIEW

The prevalence of hypertension in adolescents and young adults has increased in part due to the obesity epidemic. The clinical impact and future cardiovascular risk of this underestimated public health problem is an evolving field.

RECENT FINDINGS

The development of hypertension is predicted by tracking of elevated blood pressure from childhood to adulthood. Young hypertensive individuals have lower awareness, slower diagnosis rates, and poorer blood pressure control than older patients. Increased awareness, appropriate screening, early identification, and individualized treatment approaches for elevated blood pressure could prevent development of hypertension in adulthood and cardiovascular events in later life. The optimal blood pressure management for young adults with a low 10-year risk of atherosclerotic cardiovascular disease of < 10% remains challenging due to lack of randomized controlled trials. Evidence-based recommendations are needed to implement appropriate measures for time of treatment initiation, preferred antihypertensive drug class to be used and optimal target blood pressure level from childhood through young adulthood.

Effects of L-Citrulline Supplementation and Aerobic Training on Vascular Function in Individuals with Obesity across the Lifespan

Children with obesity are at higher risk for developing cardiometabolic diseases that once were considered health conditions of adults. Obesity is commonly associated with cardiometabolic risk factors such as dyslipidemia, hyperglycemia, hyperinsulinemia and hypertension that contribute to the development of endothelial dysfunction. Endothelial dysfunction, characterized by reduced nitric oxide (NO) production, precedes vascular abnormalities including atherosclerosis and arterial stiffness. Thus, early detection and treatment of cardiometabolic risk factors are necessary to prevent deleterious vascular consequences of obesity at an early age. Non-pharmacological interventions including L-Citrulline (L-Cit) supplementation and aerobic training stimulate endothelial NO mediated vasodilation, leading to improvements in organ perfusion, blood pressure, arterial stiffness, atherosclerosis and metabolic health (glucose control and lipid profile). Few studies suggest that the combination of L-Cit supplementation and exercise training can be an effective strategy to counteract the adverse effects of obesity on vascular function in older adults. Therefore, this review examined the efficacy of L-Cit supplementation and aerobic training interventions on vascular and metabolic parameters in obese individuals.

Impact of Pediatric Obesity on Diurnal Blood Pressure Assessment and Cardiovascular Risk Markers

Background: The prevalence of hypertension is increasing particularly among obese children and adolescents. Obese children and adolescents with hypertension are likely to remain hypertensive as they reach adulthood and hypertension is linked to an increased risk for cardiovascular disease. Twenty-four-hour ambulatory blood pressure monitoring (ABPM) has become one of the most important tools in diagnosing hypertension in children and adolescents and circadian patterns of blood pressure may be important disease-risk predictors. Methods: A retrospective chart review was conducted in patients aged 6-21 years who underwent 24-h ABPM at Kentucky Children's Hospital (KCH) from August 2012 through June 2017. Exclusion criteria included conditions that could affect blood pressure including chronic kidney disease and other renal abnormalities, congenital heart disease, cancer, and thyroid disease. Subjects were categorized by body mass index into normal (below 85th percentile), overweight (85th-95th percentile), stage I obesity (95th-119th percentile), stage II obesity (120th-139th) and stage III obesity (>140th). Non-dipping was defined as a nocturnal BP reduction of <10%. Results: Two hundred and sixty-three patients (156 male patients) were included in the analysis, of whom 70 were normal weight, 33 overweight, 55 stage I obesity, 53 stage II, and 52 stage III obesity. Although there was no significant difference between normal weight and obese groups for prevalence of hypertension, there was a greater prevalence of SBP non-dipping in obese patients as BMI increased (p = 0.008). Furthermore, non-dippers had a significantly elevated LVMI as well as abnormal lab values for uric acid, blood lipid panel, creatinine, and TSH (p < 0.05). Conclusions: These findings demonstrate that obese children and adolescents constitute a large proportion of hypertensive children and adolescents and the severity of pediatric obesity is associated with nocturnal BP non-dipping. Additionally, obesity in children is linked to several cardiovascular risk factors including left ventricular hypertrophy, dyslipidemia, and elevated uric acid levels. Further studies utilizing ABPM measures on risk stratification in this very high-risk population are warranted.

Early Vascular Aging in Children With Type 1 Diabetes and Ambulatory Normotension

Background: Preliminary data suggest that target organ damage (TOD) and early vascular aging (EVA) may occur in children with normal blood pressure (BP). Objectives: To analyze TOD and EVA in normotensive (BP <95th percentile on ambulatory BP monitoring) type 1 diabetes children (T1D) in comparison to healthy controls (C). Subjects: 25 T1D aged 13.9 ± 2.6 years and 22 C aged 14.0 ± 3.4 years. Methods: We analyzed age- and height-related pulse wave velocity (PWV) Z-scores and expected PWV based on age, height, and mean arterial pressure (MAP). Expected vascular age based on measured PWV was calculated from pooled pediatric and adult PWV norms. Left ventricular mass index (LVMI), estimated glomerular filtration rate (eGFR), and urinary albumin/creatinine ratio (ACR) were obtained as markers of TOD. Results: T1D and C groups did not differ in anthropometry, ambulatory, LVMI, and ACR. However, median age- and height-related PWV Z-scores were higher in T1D compared to C (1.08 vs. 0.57, p = 0.006; 0.78 vs. 0.36, p = 0.02, respectively). Mean (±SD) difference between measured and expected PWV was 0.58 ± 0.57 in T1D vs. 0.22 ± 0.59 in C, p = 0.02. The mean (±SD) difference between chronological and expected vascular age was 7.53 ± 7.74 years in T1D vs. 2.78 ± 7.01 years in C, p = 0.04. Conclusion: Increased arterial stiffness and increased intraindividual differences between expected and measured PWV as well as between chronological and expected vascular age indicate that EVA may develop in T1D children even at normal ambulatory BP levels.

Arterial Remodeling of the Intracranial Arteries in Patients With Hypertension and Controls: A Postmortem Study

The intracranial arteries play a major role in cerebrovascular disease, but arterial remodeling due to hypertension has not been well described in humans. We aimed to quantify this remodeling for: the basilar artery, the vertebral, internal carotid, middle/anterior (inferior)/posterior cerebral, posterior communicating, and superior cerebellar arteries of the circle of Willis. Ex vivo circle of Willis specimens, selected from individuals with (n=24) and without (n=25) a history of hypertension, were imaged at 7T magnetic resonance imaging using a 3-dimensional gradient-echo sequence. Subsequently, histological analysis was performed. We validated the vessel wall thickness and area measurements from magnetic resonance imaging against histology. Next, we investigated potential differences in vessel wall thickness and area between both groups using both techniques. Finally, using histological analysis, we investigated potential differences in arterial wall stiffness and atherosclerotic plaque severity and load. All analyses were unadjusted. Magnetic resonance imaging and histology showed comparable vessel wall thickness (mean difference: 0.04 mm (limits of agreement:-0.12 to 0.19 mm) and area (0.43 mm² [-0.97 to 1.8 mm²]) measurements. We observed no statistically significant differences in vessel wall thickness and area between both groups using either technique. Histological analysis showed early and advanced atherosclerotic plaques in almost all arteries for both groups. The arterial wall stiffness was significantly higher for the internal carotid artery in the hypertensive group. Concluding, we did not observe vessel wall thickening in the circle of Willis arteries in individuals with a history of hypertension using either technique. Using histological analysis, we observed a difference in vessel wall composition for the internal carotid artery.

Origins of Primary Hypertension in Children

Although relatively rare in childhood, primary hypertension (PH) is thought to have originated in childhood and may be even determined perinatally. PH prevalence increases in school-age children and affects 11% of 18-year-old adolescents. Associated with metabolic risk factors, elevated blood pressure in childhood is carried into adulthood. Analysis of the phenotype of hypertensive children has revealed that PH is a complex of anthropometric and neuro-immuno-metabolic abnormalities, typically found in hypertensive adults. Children with elevated blood pressure have shown signs of accelerated biological development, which are closely associated with further development of PH, metabolic syndrome, and cardiovascular disease in adulthood. At the time of diagnosis, hypertensive children were reported to have significant arterial remodelling expressed as significantly increased carotid intima-media thickness, increased stiffness of large arteries, lower area of microcirculation, and decreased endothelial function. These changes indicate that their biological age is 4 to 5 years older than their normotensive peers. All these abnormalities are typical features of early vascular aging described in adults with PH. However, as these early vascular changes in hypertensive children are closely associated with features of accelerated biological development and neuro-immuno-metabolic abnormalities observed in older subjects, it seems that PH in childhood is not only an early vascular aging event, but also an early biological maturation phenomenon.

Trends in Sodium Intake in Children and Adolescents in the US and the Impact of US Department of Agriculture Guidelines: NHANES 2003-2016

OBJECTIVE

To examine trends in sodium intake and the impact of nutritional guidelines in the US pediatric population.

STUDY DESIGN

Sodium intake data collected between 2003 and 2016 in the US National Health and Nutrition Examination Surveys (NHANES) were analyzed. Trends in intake for individuals aged 4-17 years and subgroups based on age, sex, and race and ethnicity were examined. Adherence to US Department of Agriculture guidelines was assessed.

RESULTS

A total of 16 013 individuals (50.6% male) were included in the analysis. The median sodium intake was 2840 mg/day (95% CI, 2805-2875 mg/day), decreasing from 2912 mg/day (95% CI 2848-2961 mg/day) in 2003-2004 to 2787 mg/day (95% CI, 2677-2867 mg/day) in 2015-2016 (P = .005). Intake increased with age (2507 mg/day for individuals aged 4-8, 2934 mg/day for those aged 9-13 years, and 3124 mg/day for those aged 14-17 years; P < .001) and was greater in males than in females (3053 mg/day vs 2624 mg/day; P < .001). Caucasians, Hispanics, and African Americans consumed 2860, 2733, and 2880 mg/day, respectively (P < .001). Population adherence to US Department of Agriculture recommendations was 25.0% in 2003-2010 and 25.5% in 2011-2016 (P = .677). No age, sex, or racial/ethnicity subgroup had an adherence rate >30% after implementation of pediatric guidelines in 2010.

CONCLUSIONS

Sodium intake remains elevated in all pediatric population segments, and guideline adherence is poor. A greater effort to reduce sodium consumption is needed to mitigate future cardiovascular disease risk.

Ambulatory Blood Pressure Monitoring in Pediatrics

PURPOSE OF REVIEW

This is a review of ambulatory blood pressure monitoring (ABPM) use in pediatrics, summarizing current knowledge and uses of ABPM.

RECENT FINDINGS

Updated guidelines from the American Academy of Pediatrics have emphasized the value of ABPM. ABPM is necessary to diagnose white coat hypertension, masked hypertension, and nocturnal hypertension associated with specific conditions. There is growing evidence that ABPM may be useful in these populations. ABPM has been demonstrated to be more predictive of end-organ damage in pediatric hypertension compared to office blood pressure. ABPM is an important tool in the diagnosis and management of pediatric hypertension. Routine use of ABPM could potentially prevent early cardiovascular morbidity and mortality in a wide variety of populations.

Association of Blood Pressure Level With Left Ventricular Mass in Adolescents

Hypertension is associated with left ventricular hypertrophy (LVH), a risk factor for cardiovascular events. Since cardiovascular events in youth are rare, hypertension has historically been defined by the 95th percentile of the normal blood pressure (BP) distribution in healthy children. The optimal BP percentile associated with LVH in youth is unknown. We aimed to determine the association of systolic BP (SBP) percentile, independent of obesity, on left ventricular mass index (LVMI), and to estimate which SBP percentile best predicts LVH in youth. We evaluated SBP, anthropometrics, and echocardiogram in 303 adolescents (mean age 15.6 years, 63% white, 55% male) classified by SBP as low-risk (L=141, <80th percentile), mid-risk (M=71, 80-<90th percentile), or high-risk (H=91, ≥90th percentile) using the mean of 6 measurements at 2 visits according to the 2017 guidelines. Logistic regression was used to determine the sensitivity and specificity of various SBP percentiles associated with LVH. Results: BP groups did not differ by age or demographics but differed slightly by body mass index. Mean BP, LVMI, and prevalence of LVH increased across groups (BP: L=111/75, M=125/82, and H=133/92 mm Hg; LVMI: L=31.2, M=34.2, and H=34.9 g/m^2.7; LVH: L=13%, M=21%, H=27%, all P<0.03). SBP percentile remained a significant determinant of LVMI after adjusting for covariates. The 90th percentile for SBP resulted in the best balance between sensitivity and specificity for predicting LVH (LVMI≥38.6 g/m^2.7). Abnormalities in cardiac structure in youth can be found at BP levels below those used to define hypertension.

Predictors and Consequences of Pediatric Hypertension: Have Advanced Echocardiography and Vascular Testing Arrived?

PURPOSE OF REVIEW

Pediatric hypertension is relatively common and associated with future adult hypertension. Elevated blood pressure in youth predicts future adult cardiovascular disease and blood pressure control can prevent progression of pediatric kidney disease. However, pediatric blood pressure is highly variable within a given child and among children in a population.

RECENT FINDINGS

Therefore, modalities to index aggregate and cumulative blood pressure status are of potential benefit in identifying youth in danger of progression from a risk factor of subclinical phenotypic alteration to clinically apparent event. In this review, we advocate for the health risk stratification roles of echocardiographically assessed cardiac remodeling, arterial stiffness assessment, and assessment by ultrasound of arterial thickening in children and adolescents with hypertension.

Management of high blood pressure in children: similarities and differences between US and European guidelines

Over the last several decades, many seminal longitudinal cohort studies have clearly shown that the antecedents to adult disease have their origins in childhood. Hypertension (HTN), which has become increasingly prevalent in childhood, represents one of the most important risk factors for cardiovascular diseases (CVD) such as heart disease and stroke. With the risk of adult HTN much greater when HTN is manifest in childhood, the future burden of CVD worldwide is therefore concerning. In an effort to slow the current trajectory, professional societies have called for more rigorous, evidence-based guideline development to aid primary care providers and subspecialists in improving recognition, diagnosis, evaluation, and treatment of pediatric HTN. In 2016 the European Society of Hypertension and in 2017 the American Academy of Pediatrics published updated guidelines for prevention and management of high blood pressure (BP) in children. While there are many similarities between the two guidelines, important differences exist. These differences, along with the identified knowledge gaps in each, will hopefully spur clinical researchers to action. This review highlights some of these similarities and differences, focusing on several of the more important facets regarding prevalence, prevention, diagnosis, management, and treatment of childhood HTN.

Central systolic blood pressure and central pulse pressure predict left ventricular hypertrophy in hypertensive children

BACKGROUND

Central systolic and pulse pressures are stronger predictors of cardiovascular risk and hypertensive organ damage than brachial blood pressure. It is suggested that isolated systolic hypertension typically seen in adolescents is associated with normal central blood pressure and does not lead to organ damage and this phenomenon is called spurious hypertension.

METHODS

We assessed the prevalence of spurious hypertension and analyzed utility of pulse wave analysis as determinant of hypertensive organ damage in 294 children (62 girls; 15.0 ± 2.4 years) diagnosed as primary hypertension. White coat hypertension, ambulatory prehypertension, ambulatory hypertension, and severe ambulatory hypertension were diagnosed in 127, 29, 41, and 97 patients, respectively.

RESULTS

Normal central blood pressure was found in 100% in patients with white coat hypertension, 93% in pre-hypertensives, 51.2% in those with ambulatory hypertension, and 27.8% with severe ambulatory hypertension (p = 0.0001). Children with severe ambulatory hypertension had higher central systolic and pulse pressure, pulse wave velocity, and greater prevalence of left ventricular hypertrophy than white coat and prehypertensive children (p < 0.05). Left ventricular mass index and carotid intima-media thickness correlated with central systolic and pulse pressure (p < 0.05 for all). Receiver operating curve area was similar for augmentation pressure (0.5836), 24-h ambulatory systolic blood pressure (0.5841), central systolic blood pressure (0.6090), and central pulse pressure (0.5611) as predictors of left ventricular hypertrophy.

CONCLUSIONS

These findings suggest that pulse wave analysis is complementary to ambulatory blood pressure monitoring in assessment of risk of organ damage in hypertensive adolescents.

Complete blood count-derived inflammatory markers in adolescents with primary arterial hypertension: a preliminary report

Aim of the study

The aim of our study was to evaluate selected inflammatory markers in children with untreated primary hypertension and to establish the relation between inflammatory markers and 24-hour ambulatory blood pressure monitoring (ABPM) and clinical and biochemical parameters.

Material and methods

In 54 children (15.12 ±2.02 years) with untreated primary hypertension, with excluded overt inflammation, we evaluated: neutrophils (NEU; 1000/μl), lymphocytes (LYM; 1000/μl), platelets (PLT; 1000/μl), mean platelet volume (MPV; fl), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), ABPM (OSCAR 2 SUNTECH), and selected clinical and biochemical parameters. The control group consisted of 20 healthy children (15.55 ±2.27 years).

Results

Children with primary hypertension had (p < 0.01) higher 24-hour systolic, diastolic and mean blood pressure, systolic and diastolic blood pressure loads, and pulse pressure. Hypertensive children did not differ in inflammatory indicators (NEU, LYM, PLT, MPV, NLR, PLR) from the control group. In 54 hypertensive children we found the following correlations: between office systolic and diastolic blood pressure and MPV (r = 0.35, p = 0.011, r = 0.36, p = 0.008), between 24-hour ambulatory mean arterial pressure Z-score and NLR (r = 0.30, p = 0.030), 24-hour systolic blood pressure load and NLR (r = 0.38, p = 0.005), plasma renin activity and neutrophil count, NLR, PLR (r = 0.47, p = 0.016, r = 0.64, p < 0.001, r = 0.42, p = 0.033), urinary albumin loss and neutrophil count, NLR (r = 0.46, p = 0.001 and r = 0.42, p = 0.003). Multivariate analysis revealed that office SBP Z-score was related to MPV (β = 0.35, p = 0.008) and albuminuria to neutrophil count (β = 0.62, p = 0.018).

Conclusions

In children with primary arterial hypertension there may be a relation between blood pressure, urinary albumin loss, and subclinical inflammation.

Pharmacological Treatment of Arterial Hypertension in Children and Adolescents: A Network Meta-Analysis

Pharmacological treatment is indicated in children and adolescents with hypertension unresponsive to lifestyle modifications, but there is not enough evidence to recommend 1 class of antihypertensive drugs over others. We performed a network meta-analysis to compare the results of available randomized clinical trials on pharmacological treatment of pediatric hypertension. From a total of 554 potentially relevant studies, 13 randomized placebo-controlled clinical trials enrolling ≥50 patients and a follow-up ≥4 weeks were included. The reduction of systolic blood pressure (SBP) and diastolic BP (DBP) after treatment were the coprimary end points. A total of 2378 pediatric patients, with a median age of 12 years, were included in the analysis. After a median follow-up of 35 days, lisinopril and enalapril were found to be superior to placebo in reducing SBP and DBP, whereas only for DBP, losartan was found to be superior to placebo and lisinopril and enalapril were found to be superior to eplerenone. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers were associated with a greater SBP and DBP reduction compared with placebo, likewise the mineralocorticoid receptor antagonist was inferior to angiotensin-converting enzyme inhibitors in DBP reduction. The analysis was adjusted for study-level mean age, percentage of women, mean baseline blood pressure, and mean weight, only the latter significantly affected DBP reduction. According to the present analysis, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers could represent the best choice as antihypertensive treatment for pediatric hypertension. However, because of the paucity of available data for the other classes of antihypertensive drugs, definitive conclusions are not allowed and further randomized controlled trials are warranted.

The Childhood Role in Development of Primary Hypertension

Primary hypertension is not just an adult disorder. Current US population data on children and adolescents demonstrate a prevalence of elevated blood pressure (BP) and hypertension combined of over 10%. Recent reports from prospective cohort studies describe an association of high BP in childhood with hypertension in young adulthood. Excess adiposity is strongly associated with higher BP in childhood and increases risk for hypertension in adulthood. In addition to overweight/obesity, other exposures that raise the risk for high BP include low birthweight, dietary sodium, and stress. Using intermediate markers of cardiovascular injury, studies on hypertensive children report findings of cardiac hypertrophy, vascular stiffness, and early atherosclerotic changes. Impaired cognitive function has also been demonstrated in hypertensive children. Recent advances in clinical and translational research support the concept that the evolution of primary hypertension begins in childhood.

2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents

Increasing prevalence of hypertension (HTN) in children and adolescents has become a significant public health issue driving a considerable amount of research. Aspects discussed in this document include advances in the definition of HTN in 16 year or older, clinical significance of isolated systolic HTN in youth, the importance of out of office and central blood pressure measurement, new risk factors for HTN, methods to assess vascular phenotypes, clustering of cardiovascular risk factors and treatment strategies among others. The recommendations of the present document synthesize a considerable amount of scientific data and clinical experience and represent the best clinical wisdom upon which physicians, nurses and families should base their decisions. In addition, as they call attention to the burden of HTN in children and adolescents, and its contribution to the current epidemic of cardiovascular disease, these guidelines should encourage public policy makers to develop a global effort to improve identification and treatment of high blood pressure among children and adolescents.

Methods to evaluate arterial structure and function in children - State-of-the art knowledge

BACKGROUND

With increasing rates of hypertension, obesity, and diabetes in the pediatric population, wide available, and reproducible methods are necessary to evaluate arterial structure and function in children and adolescents.

METHODS

MEDLINE/Pubmed was searched for articles published in years 2012-2017 on methodology of, current knowledge on, and limitations of the most commonly used methods to evaluate central, proximal and coronary arteries, as well as endothelial function in pediatric patients.

RESULTS

Among 1528 records screened (including 1475 records from years 2012 to 2017) 139 papers were found suitable for the review. Following methods were discussed in this review article: ultrasound measurements of the intima-media thickness, coronary calcium scoring using computed tomography, arterial stiffness measurements (pulse wave velocity and pulse wave analysis, carotid artery distensibility, pulse pressure, and ambulatory arterial stiffness index), ankle-brachial index, and methods to evaluate vascular endothelial function (flow-mediated vasodilation, peripheral arterial tonometry, Doppler laser flowmetry, and cellular and soluble markers of endothelial dysfunction).

CONCLUSIONS

Ultrasonographic measurement of carotid intima-media thickness and measurement of pulse wave velocity (by oscillometry or applanation tonometry) are highly reproducible methods applicable for both research and clinical practice with proved applicability for children aged ≥6 years or with height ≥120cm. Evaluation of ambulatory arterial stiffness index by ambulatory blood pressure monitoring is another promising option in pediatric high-risk patients. Clearly, further studies are necessary to evaluate usefulness of these and other methods for the detection of subclinical arterial damage in children.

The association between blood pressure and carotid intima-media thickness in children: a systematic review

High blood pressure is a risk factor for atherosclerosis in adults, but whether the same is true in children and young people is not known. This is important to guide management of high blood pressure in children and young people. We aimed to investigate the association in children and young people between blood pressure and carotid intima-media thickness, a non-invasive marker of atherosclerosis, through a systematic review. Studies were retrieved from MEDLINE and EMBASE. Articles were eligible for inclusion if they included at least one measurement of blood pressure and at least one measurement of ultrasound-derived carotid intima-media thickness, both measured during childhood (0-19 years), and a measure of effect size or correlation between the two measurements. A total of 3748 studies were identified in the initial search, of which 28 studies were included in this review. The results were mixed, but the largest and highest-quality studies suggested an independent positive association between blood pressure and carotid intima-media thickness in children and young people, even after adjustment for other cardiovascular risk factors. There was no indication of a clear threshold level for the effect of blood pressure on carotid intima-media thickness, hence there are insufficient data to support a pharmacological treatment threshold for the treatment of high blood pressure in children and young people to prevent future cardiovascular disease. The studies included varied widely in terms of quality and design, and it was not possible to combine the data in a meta-analysis. There is likely to be an independent association between blood pressure and carotid intima-media thickness in childhood, but it is not clear at what point this should be treated.

Primary Pediatric Hypertension: Current Understanding and Emerging Concepts

The rising prevalence of primary pediatric hypertension and its tracking into adult hypertension point to the importance of determining its pathogenesis to gain insights into its current and emerging management. Considering that the intricate control of BP is governed by a myriad of anatomical, molecular biological, biochemical, and physiological systems, multiple genes are likely to influence an individual's BP and susceptibility to develop hypertension. The long-term regulation of BP rests on renal and non-renal mechanisms. One renal mechanism relates to sodium transport. The impaired renal sodium handling in primary hypertension and salt sensitivity may be caused by aberrant counter-regulatory natriuretic and anti-natriuretic pathways. The sympathetic nervous and renin-angiotensin-aldosterone systems are examples of antinatriuretic pathways. An important counter-regulatory natriuretic pathway is afforded by the renal autocrine/paracrine dopamine system, aberrations of which are involved in the pathogenesis of hypertension, including that associated with obesity. We present updates on the complex interactions of these two systems with dietary salt intake in relation to obesity, insulin resistance, inflammation, and oxidative stress. We review how insults during pregnancy such as maternal and paternal malnutrition, glucocorticoid exposure, infection, placental insufficiency, and treatments during the neonatal period have long-lasting effects in the regulation of renal function and BP. Moreover, these effects have sex differences. There is a need for early diagnosis, frequent monitoring, and timely management due to increasing evidence of premature target organ damage. Large controlled studies are needed to evaluate the long-term consequences of the treatment of elevated BP during childhood, especially to establish the validity of the current definition and treatment of pediatric hypertension.

The Use of Ambulatory Blood Pressure Monitoring As Standard of Care in Pediatrics

Hypertension (HTN) is a significant global health problem, responsible for 7.5 million deaths each year worldwide. The prevalence of HTN is increasing in the pediatric population likely attributed to the increase in childhood obesity. Recent work has also shown that blood pressure (BP) tends to track from childhood to adulthood including BP-related target organ damage. In the last 25-30 years, pediatric use of ambulatory blood pressure monitoring (ABPM) has been expanding mainly in the setting of initial elevated BP measurement evaluation, HTN therapy efficacy follow-up, and renal disease. However, there are many clinical areas where ABPM could potentially be used but is currently underutilized. This review summarizes the current knowledge and the uses of pediatric ABPM and explores clinical areas where it can be very useful both to detect HTN and its longitudinal follow-up. And thus, ABPM could serve as a critical tool to potentially prevent early cardiovascular mortality and morbidity in wide variety of populations. With solid data to support ABPM's superiority over clinic BP measurements and these clinical areas for its expansion, ABPM should now be part of standard of care in BP evaluation and management in pediatrics.

Left Ventricular Hypertrophy in Pediatric Hypertension: A Mini Review

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.

Predictors of carotid intima media thickness in obese adolescents

Our aim was to assess cardiovascular risk factors that may predict increased carotid intima media thickness (cIMT) in obese children and adolescents. Children and adolescents were included in the cross-sectional study if they were aged 9-19 years and had primary obesity. Besides anthropometric and biochemical measurements, ambulatory blood pressure monitoring, measurement of carotid intima media thickness and exercise stress test were performed. We included 103 obese patients and divided them according to the ambulatory blood pressure findings in two groups: obese patients with and without ambulatory hypertension. There were 49 obese patients with and 54 without ambulatory hypertension Univariate analysis showed that there was a significant positive correlation of cIMT with age (r = 0.334, p = 0.001), body mass index (r = 0.288, p = 0.004), waist circumference (r = 0.352, p = 0.000), hip circumference (r = 0.288, p = 0.004), night-time systolic blood pressure (r = 0.226, p = 0.027), and peak diastolic blood pressure on exercise test (r = 0.241, p = 0.018). In a stepwise model, age, waist circumference and peak diastolic blood pressure on exercise test were independent predictors of cIMT.

Preschool children blood pressure percentiles by age and height

We aimed to construct blood pressure (BP) references for the Polish preschool children and to compare them with the United States, German and European references. BP was measured oscillometrically using a validated device in 4378 randomly selected Polish children aged 3-6 years who were free of chronic diseases and behaved quietly during BP measurement. Height and weight were also measured. Gender-specific BP percentiles were constructed for age and height simultaneously with the use of quantile regression and a polynomial regression model. Systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial blood pressure reference percentiles by gender, age and height are presented. The Polish preschool children's 90th and 95th SBP and DBP percentiles were mostly lower than those in the United States, German and IDEFICS study BP references. Compared with the German oscillometric BP reference and with the United States sphygmomanometric BP reference, differences in the 95th SBP percentiles ranged by age from -5 to 0 mm Hg and from -2 to -1 mm Hg, in boys and girls, respectively, whereas the differences in the 95th percentiles of DBP ranged from -7 to -1 mm Hg and from -5 to -1 mm Hg, in boys and girls, respectively. Polish preschool children's BP percentiles based on measurements with the use of a validated oscillometric device in a nationally representative sample are lower than those from the current United States, German and European references. When interpreting BP measurements in children, adequate referential values should be used.

Arterial stiffness in children with and without probable developmental coordination disorder

BACKGROUND

Children with cardiovascular disease risk factors demonstrate adverse arterial alterations that are predictive of cardiovascular morbidity and mortality in adults. Children with developmental coordination disorder (DCD) are at cardiovascular risk as they are more likely to be obese and inactive.

AIM

The purpose of this study was to assess arterial structure and function in children with and without probable DCD (p-DCD).

METHODS

A cross-sectional study of 33 children with p-DCD (22 male) and 53 without (30 male). The Movement Assessment Battery for Children was used to classify those with p-DCD. Adiposity was assessed using the BOD POD. Compliance, distensibility, and intima-media thickness were measured at the common carotid artery (CCA). ECG R-wave-to-toe pulse wave velocity (PWV) was also measured.

RESULTS

Compared to controls, males with p-DCD had lower CCA distensibility (p=0.034) and higher PWV (p=0.001). No differences were evident in females. Body fat percent was a significant predictor of CCA distensibility and removed the effect of p-DCD on PWV in males.

CONCLUSIONS

The present study demonstrates augmented arterial stiffness in males with p-DCD, likely attributed to body fat. These findings underscore the importance of targeted interventions in children with p-DCD, specifically males, in order to prevent future cardiovascular risk.

Assessment of Left Ventricular Mass and Hypertrophy by Cardiovascular Magnetic Resonance Imaging in Pediatric Hypertension

Cardiovascular magnetic resonance (CMR) imaging in adults is considered the gold standard for assessment of left ventricular mass (LVM) and left ventricular hypertrophy (LVH). The authors aimed to evaluate agreement of LVM measurements and LVH determination between echocardiography (ECHO) and CMR imaging in children with hypertension (HTN) confirmed by 24-hour ambulatory blood pressure monitoring (ABPM). The children (n=22) underwent contemporaneous ECHO, CMR imaging, and ABPM. Patients had a mean body mass index of 30.9±7.5 (kg/m2 ), and 81.8% had severe HTN. LVM measured by ECHO was 189.6±62.1 g and by CMR imaging was 164.6±44.7 g (P<.0001). Bland-Altman analysis revealed significant variability between ECHO and CMR imaging in the measurement of LVM. Interobserver error was higher with ECHO than with CMR imaging. ECHO had high sensitivity and low specificity in LVH determination. In conclusion, ECHO overestimates LVM and is less accurate in measuring LVM as compared with CMR imaging in children with HTN. Further prospective study using CMR imaging to assess LVM in children is warranted.

Circadian and ultradian cardiovascular rhythmicity in obese children

Altered circadian and ultradian blood pressure (BP) and heart rate (HR) rhythmicity have been described in diseases with increased cardiovascular risk. We analyzed cardiovascular rhythmicity in obese children. BP and HR rhythmicity was assessed with Fourier analysis from 24-h ambulatory BP measurements in 75 obese children and compared with an age- and gender-matched, lean healthy reference group of 150 subjects. Multivariate regression analysis was applied to identify significant independent factors explaining variability of rhythmicity. Prevalence of 24- and 6-h BP rhythmicity in the obese group was lower (p = 0.03 and p = 0.02), whereas the prevalence of HR rhythmicity was comparable in both groups. Excluding hypertensive participants, the results remained similar. Twenty-four-hour BP and HR acrophase were delayed in obese children (p = 0.004, p < 0.0001), 24-h BP amplitude did not differ (p = 0.07), and 24-h HR amplitude was blunted (p = < 0.0001). BP Mesor in the obese group was higher (p = 0.02); HR Mesor did not differ (p = 0.1). Multivariate regression analysis failed to identify a single anthropometric or blood pressure parameter explaining the variability of BP and HR rhythmicity.

CONCLUSION

Prevalence and parameters of circadian and ultradian BP and HR rhythmicity in obese children are altered compared to a healthy reference group, independent of preexisting hypertension.

WHAT IS KNOWN

• Altered cardiovascular rhythmicity has been described in children with different diseases such as primary hypertension or chronic renal failure. What is New: • This study reveals altered cardiovascular rhythmicity in obese children compared to an age and gender-matched healthy reference group independent from preexisting hypertension.

Nocturnal blood pressure non-dipping is not associated with increased left ventricular mass index in hypertensive children without end-stage renal failure

The aim of our study was to investigate whether nocturnal blood pressure (BP) dip is associated with increased left ventricular mass index and hypertrophy in children with hypertension (HT). We retrospectively reviewed data from all children with confirmed ambulatory HT in our center and performed ambulatory blood pressure monitoring (ABPM) and echocardiography at the same time. Left ventricular hypertrophy (LVH) was defined as left ventricular mass index (LVMI) ≥95th centile. Non-dipping phenomenon was defined as nocturnal BP dip <10 %. A total of 114 ABPM studies were included, the median age of children was 15.3 years (3.8-18.9), 80 children had renoparenchymal HT without end-stage renal failure, 34 had primary HT, and 27 studies were done on untreated children and 87 on treated children. Non-dipping phenomenon was present in 63 (55 %) studies (non-dippers). The LVMI adjusted for age was not significantly different between non-dippers and dippers (0.87 ± 0.03 vs. 0.81 ± 0.02, p = 0.13). Left ventricular hypertrophy was not significantly higher in non-dippers than in dippers (20 vs. 9 %, p = 0.12).

CONCLUSION

Hypertensive children without end-stage renal failure with non-dipping phenomenon do not have increased prevalence of LVH or higher LVMI adjusted for age than hypertensive children with preserved nocturnal BP dip.

WHAT IS KNOWN

• Adult and pediatric hypertensive patients with end-stage renal failure have often nocturnal blood pressure non-dipping phenomenon. • Non-dipping phenomenon is in patients with end-stage renal failure associated with increased prevalence of left ventricular hypertrophy. What is New: • Pediatric hypertensive patients without end-stage renal failure with blood pressure non-dipping phenomenon do not have increased prevalence of left ventricular hypertrophy.

Novelty in hypertension in children and adolescents: focus on hypertension during the first year of life, use and interpretation of ambulatory blood pressure monitoring, role of physical activity in prevention and treatment, simple carbohydrates and uric acid as risk factors

The present article intends to provide an update of the article "Focus on prevention, diagnosis and treatment of hypertension in children and adolescents" published in 2013 (Spagnolo et al., Ital J Pediatr 39:20, 2013) in this journal. This revision is justified by the fact that during the last years there have been several new scientific contributions to the problem of hypertension in pediatric age and during adolescence. Nevertheless, for what regards some aspects of the previous article, the newly acquired information did not require substantial changes to what was already published, both from a cultural and from a clinical point of view. We felt, however, the necessity to rewrite and/or to extend other parts in the light of the most recent scientific publications. More specifically, we updated and extended the chapters on the diagnosis and management of hypertension in newborns and unweaned babies, on the use and interpretation of ambulatory blood pressure monitoring, and on the usefulness of and indications for physical activity. Furthermore, we added an entirely new section on the role that simple carbohydrates (fructose in particular) and uric acid may play in the pathogenesis of hypertension in pediatric age.

The association between arterial properties and blood pressure in children

Elevated blood pressure (BP) in adults is associated with increased arterial stiffness and thickness; however, its effect on arterial health in a pediatric population is less understood. The purpose of this study was to identify the relationship between childhood BP and arterial markers of arteriosclerotic progression. The study consisted of 106 children across a wide range of BP values divided into 2 BP groups: high BP (HBP; ≥ 95th percentile; n = 21) and normal BP (NBP; < 90th percentile; n = 85) based on consistent automated BP measures taken at 2 time points. The laboratory examination involved systemic pulse wave velocity (PWV), common carotid artery (CCA) intima media thickness (IMT) and distensibility, as well as body mass index (BMI) and pubertal maturation. BMI and heart rate, as well as PWV (HBP: n = 15 and NBP: n = 56), were higher in the HBP group (p < 0.001) with no difference between groups for both CCA distensibility and IMT (HBP: n = 21 and NBP: n = 83). Multivariate linear regression revealed that BP group (p = 0.003) was an independent predictor of PWV after controlling for age, sex, BMI, heart rate, and maturation. Our findings demonstrate a higher systemic PWV with no difference in CCA IMT or distensibility in children with elevated BP. Hence, markers of cardiovascular disease risk are augmented in healthy children with elevated BP.

White-Coat and Reverse White-Coat Effects Correlate with 24-h Pulse Pressure and Systolic Blood Pressure Variability in Children and Young Adults

Masked hypertension (MH) and white-coat hypertension (WCH) are associated with organ damage. In the present study, we examined the correlation between the magnitude of white-coat effect (WCE) or reverse WCE (RWCE) and 24-h pulse pressure (PP), an indicator of target organ damage and arterial stiffness, in children and young adults. We also examined the relationship of WCE or RWCE and blood pressure (BP) variability, another predictor of clinical outcomes. One hundred and ninety-eight subjects were studied. According to the office BP and ambulatory BP, they were divided into normotension, WCH, MH, and hypertension. The magnitude of WCE or RWCE, along with male gender and 24-h systolic BP, was the determinant of 24-h PP. In subjects with 24-h PP ≥ 61 mmHg, the magnitude of WCE or RWCE, age, male ratio, height, weight, BMI, the percentage of secondary hypertension, that of MH, office systolic BP, and 24-h systolic BP were significantly greater. There was a progressive increase in 24-h PP from normotension, WCH, MH, to hypertension. BP variability in subjects with MH was numerically highest in both systolic and diastolic. Diastolic BP variability of WCH, MH, and hypertension was significantly higher than that of normotension. Finally, the magnitude of WCE or RWCE in systolic showed a significant correlation with systolic BP variability. In conclusion, the magnitude of WCE or RWCE correlates with 24-h PP and systolic BP variability, which may suggest increased arterial stiffness in WCH and MH.

Primary hypertension is a disease of premature vascular aging associated with neuro-immuno-metabolic abnormalities

There is an increasing amount of data indicating that primary hypertension (PH) is not only a hemodynamic phenomenon but also a complex syndrome involving abnormal fat tissue distribution, over-activity of the sympathetic nervous system (SNS), metabolic abnormalities, and activation of the immune system. In children, PH usually presents with a typical phenotype of disturbed body composition, accelerated biological maturity, and subtle immunological and metabolic abnormalities. This stage of the disease is potentially reversible. However, long-lasting over-activity of the SNS and immuno-metabolic alterations usually lead to an irreversible stage of cardiovascular disease. We describe an intermediate phenotype of children with PH, showing that PH is associated with accelerated development, i.e., early premature aging of the immune, metabolic, and vascular systems. The associations and determinants of hypertensive organ damage, the principles of treatment, and the possibility of rejuvenation of the cardiovascular system are discussed.