Vascular Aging: Lessons From Pediatric Hypertension

Trend of blood pressure changes among children from 2012 to 2022: findings from student health surveillance in Eastern China

OBJECTIVES

The primary objective of this study is to examine the secular trends in blood pressure levels from 2012 to 2022 in eastern China. Additionally, to compare two standards [International Blood Pressure Reference for Children and Adolescents (ICBP) and the National Blood Pressure Reference for Chinese Han Children and Adolescents (CCBP)], we calculate the 95th percentile of blood pressure levels for students in developed regions (ECCBP). Secondly, the study aims to investigate potential contributors to elevated blood pressure, including sex, age, behaviors, and mental health. Lastly, the study seeks to estimate the total population aged 7-18 years with elevated blood pressure in Eastern China based on three references.

METHODS

The data used in this study were obtained from the Student Health Surveillance program in Jiangsu Province, which has been collecting data since 2012. Trained project members, skilled nurses, and doctors measured anthropometric variables. Additionally, online student questionnaires were administered in 2017, 2019, and 2021 to collect personal information behavior patterns, and mental health.

RESULTS

The study examined blood pressure changes in 123 013 children and adolescents in Eastern China from 2012 to 2022. Significant increases were observed in systolic blood pressure (SBP) and pulse pressure difference. Prevalence of elevated blood pressure followed a similar trend with ECCBP and CCBP, ranging from 17.2%/16.3% (2012-2015) to 11.6%/14.6% (2020-2022). Notably, BP with ICBP showed a significant increase in both prevalence and population, from 12.6% [6 713 679, 95% confidence interval (CI): 6 708 931 to 6 718 427] to 14.5% (7 004 208, 95% CI: 6 999 411 to 7 009 004). The study further emphasizes the significant impact of various risk factors on elevated blood pressure among children and adolescents, particularly the detrimental effect of depression on blood pressure, with the odds ratios (OR) in 2021 being 1.310 (95% CI, 1.290-1.330) for ECCBP, 1.239 (95% CI, 1.223-1.255) for CCBP, and 1.189 (95% CI, 1.176-1.202) for ICBP.

CONCLUSION

The study revealed significant changes in the population and prevalence of elevated blood pressure in Eastern China from 2012 to 2022. The findings indicate a decline in the prevalence of elevated blood pressure (referred to as CCBP or ECCBP), while highlighting an increasing trend in elevated blood pressure (referred to as ICBP). Untreated high blood pressure can lead to serious cardiovascular diseases in adulthood, underscoring the importance of early prevention and management, particularly through nonpharmacological methods and regular monitoring for students in Eastern China. Raising awareness among educators, parents, and healthcare providers about the association between mental health and elevated blood pressure is essential.

Early Vascular Ageing in adolescents with migraine with aura: a community-based study

BACKGROUND

Migraine with aura is associated with an increased risk of cardiovascular disease, yet the pathophysiology is unknown. Suggested underlying mechanisms of aura formation point into the direction of an abnormal vasoreactivity that also extends to the extracranial vasculature.

METHODS

In the Early Vascular Ageing Tyrol study, a community-based non-randomized controlled trial conducted in 45 schools and companies in Tyrol (Austria) and South-Tyrol (Italy) between May 2015 and September 2018 aiming to increase cardiovascular health in adolescents, headache syndromes were classified according to the International Classification of Headache Disorders in a face-to-face interview. Carotid-femoral pulse-wave-velocity was measured by applanation tonometry and carotid intima-media-thickness by high-resolution ultrasound of the distal common carotid arteries. Differences in pulse-wave-velocity and carotid intima-media-thickness in youngsters with migraine with aura were compared respectively to those without headache and with other headaches by multivariable linear regression analysis.

RESULTS

Of the 2102 study participants 1589 were aged 14 to 19 (mean 16.8) years and had complete data. 43 (2.7%) reported migraine with aura and 737 (46.4%) other headaches. Mean pulse-wave-velocity was 6.17 m/s (± 0.85) for migraine with aura, 6.06 m/s (± 0.82) for all other headaches and 6.15 (0.95) m/s for participants without headaches. Carotid intima-media-thickness was 411.3 µm (± 43.5) for migraine with aura, 410.9 µm (± 46.0) for all other headaches and 421.6 µm (± 48.4) for participants without headaches. In multivariable linear regression analysis, we found no differences in carotid-femoral pulse-wave-velocity or carotid intima-media-thickness in young subjects with migraine with aura, all other headaches, or no headaches.

CONCLUSIONS

In line with previous large-scale studies in adults, we could not demonstrate relevant associations of migraine with aura with markers of arterial stiffness or subclinical atherosclerosis making early vascular ageing an unlikely pathophysiological link between migraine with aura and cardiovascular diseases.

TRIAL REGISTRATION

First registered on ClinicalTrials.gov 29/04/2019 (NCT03929692).

Chronological attenuation of NPRA/PKG/AMPK signaling promotes vascular aging and elevates blood pressure

Hypertension is common in elderly population. We designed to search comprehensively for genes that are chronologically shifted in their expressions and to define their contributions to vascular aging and hypertension. RNA sequencing was conducted to search for senescence-shifted transcripts in human umbilical vein endothelial cells (HUVECs). Small interfering RNA (siRNA), small-molecule drugs, CRISPR/Cas9 techniques, and imaging were used to determine genes' function and contributions to age-related phenotypes of the endothelial cell and blood vessel. Of 25 genes enriched in the term of "regulation of blood pressure," NPRA was changed most significantly. The decreased NPRA expression was replicated in aortas of aged mice. The knockdown of NPRA promoted HUVEC senescence and it decreased expressions of protein kinase cGMP-dependent 1 (PKG), sirtuin 1 (SIRT1), and endothelial nitric oxide synthase (eNOS). Suppression of NPRA also decreased the phosphorylation of AMP-activated protein kinase (AMPK) as well as the ratio of oxidized nicotinamide adenine dinucleotide (NAD⁺ )/reduced nicotinamide adenine dinucleotide (NADH) but increased the production of reactive oxygen species (ROS). 8-Br-cGMP (analog of cGMP), or AICAR (AMPK activator), counteracted the observed changes in HUVECs. The Npr1^+/- mice presented an elevated systolic blood pressure and their vessels became insensitive to endothelial-dependent vasodilators. Further, vessels from Npr1^+/- mice increased Cdkn1a but decreased eNos expressions. These phenotypes were rescued by intravenously administrated 8-Br-cGMP and viral overexpression of human PKG, respectively. In conclusion, we demonstrate NPRA/PKG/AMPK as a novel and critical signaling axis in the modulation of endothelial cell senescence, vascular aging, and hypertension.

What Level of Blood Pressure Is Concerning in Childhood?

The 95th percentile of blood pressure (BP) among healthy children is the currently accepted level used to denote a hypertensive BP reading in pediatric patients. Yet, ample data have emerged showing that the detrimental effects of high BP can be demonstrated at BP levels considered normal by current guidelines. Cardiac, vascular, cognitive, and kidney effects have been shown starting at the 90th percentile in cross-sectional studies, and markers of adult cardiovascular disease appear in longitudinal cohorts whose members had modestly elevated or even normal BP as youth. This review summarizes data that support a lower threshold of concern for children and adolescents, and outlines some of the remaining questions to be answered before a lower threshold BP level could be adopted.

Diagnostic accuracy of anthropometric indices for discriminating elevated blood pressure in pediatric population: a systematic review and a meta-analysis

BACKGROUND

Childhood obesity is more likely to increase the chance of many adult health problems. Numerous studies have shown obese children to be more prone to elevated blood pressure (BP) and hypertension. It is important to identify an obesity anthropometric index with good discriminatory power for them in pediatric population.

METHODS

MEDLINE/PubMed, Web of Science, and Cochrane databases were retrieved comprehensively for eligible studies on childhood obesity and hypertension/elevated BP through June 2021. The systematic review and meta-analysis of studies used receiver operating characteristics (ROC) curves for evaluating the discriminatory power of body mass index (BMI), waist circumference (WC), and waist-to-height ratio (WHtR) in distinguishing children with elevated BP and hypertension.

RESULTS

21 cross-sectional studies involving 177,943 children and 3-19 years of age were included in our study. Meta-analysis showed that the pooled area under the reporting receiver-operating characteristic curves (AUC) and 95% confidence intervals (CIs) for BMI, WC, and WHtR to detect hypertension of boys were 0.68 (0.64, 0.72), 0.69 (0.64, 0.74), 0.67 (0.63, 0.71), for elevated BP, the pooled AUCs and 95% CIs were 0.67 (0.61, 0.73), 0.65 (0.58, 0.73), 0.65 (0.61, 0.71). The pooled AUCs and 95% CIs for BMI, WC and WHtR of predicting hypertension were 0.70 (0.66, 0.75), 0.69 (0.64, 0.75), 0.67 (0.63, 0.72) in girls, the pooled AUCs and 95% CIs of predicting elevated BP were 0.63 (0.61, 0.65), 0.62 (0.60, 0.65), 0.62 (0.60, 0.64) respectively. There was no anthropometric index was statistically superior in identifying hypertension and elevated BP, however, the accuracy of BMI predicting hypertension was significantly higher than elevated BP in girls (P < 0.05). The subgroup analysis for the comparison of BMI, WC and WHtR was performed, no significant difference in predicting hypertension and elevated BP in pediatric population.

CONCLUSIONS

This systematic review showed that no anthropometric index was superior in identifying hypertension and elevated BP in pediatric population. While compared with predicting elevated BP, all the indicators showed superiority in predicting hypertension in children, the difference was especially obvious in girls. A better anthropometric index should be explored to predict children's early blood pressure abnormalities.

Racial differences of early vascular aging in children and adolescents

The prevalence of non-communicable disease (NCDs) is rising globally, with a large burden recorded in sub-Saharan countries and populations of black race/ethnicity. Accelerated vascular deterioration, otherwise known as early vascular aging (EVA), is the underlying factor for highly prevalent NCDs such as hypertension. The etiology of EVA is multifactorial with a central component being arterial stiffness with subsequent development of hypertension and cardiovascular complications. Although arterial stiffness develops with increasing age, many children and adolescents are subjected to the premature development of arterial stiffness, due to genetic or epigenetic predispositions, lifestyle and behavioral risk factors, and early life programming. Race/ethnic differences in pediatric populations have also been reported with higher aortic stiffness in black (African American) compared with age-matched white (European American) counterparts independent of blood pressure, body mass index, or socioeconomic status. With known evidence of race/ethnic differences in EVA, the pathophysiological mechanisms underlying graded differences in the programming of EVA are still sparse and rarely explored. This educational review aims to address the early life determinants of EVA in children and adolescents with a particular focus on racial or ethnic differences.

Obesity, metabolic syndrome, and primary hypertension

Primary hypertension is the dominant form of arterial hypertension in adolescents. Disturbed body composition with, among other things, increased visceral fat deposition, accelerated biological maturation, metabolic abnormalities typical for metabolic syndrome, and increased adrenergic drive constitutes the intermediary phenotype of primary hypertension. Metabolic syndrome is observed in 15-20% of adolescents with primary hypertension. These features are also typical of obesity-related hypertension. Metabolic abnormalities and metabolic syndrome are closely associated with both the severity of hypertension and the risk of target organ damage. However, even though increased body mass index is the main determinant of blood pressure in the general population, not every hypertensive adolescent is obese and not every obese patient suffers from hypertension or metabolic abnormalities typical for metabolic syndrome. Thus, the concepts of metabolically healthy obesity, normal weight metabolically unhealthy, and metabolically unhealthy obese phenotypes have been developed. The risk of hypertension and hypertensive target organ damage increases with exposure to metabolic risk factors which are determined by disturbed body composition and visceral obesity. Due to the fact that both primary hypertension and obesity-related hypertension present similar pathogenesis, the principles of treatment are the same and are focused not only on lowering blood pressure, but also on normalizing body composition and metabolic abnormalities.

Early Vascular Aging in Children With Tuberous Sclerosis Complex

Objectives: Experimental data indicate that activating mutations in the mTOR (mammalian target of rapamycin) pathway may lead to abnormal arterial wall structure. Vascular anomalies like arterial stenoses are reported in pediatric patients with tuberous sclerosis complex (TSC). In addition, large renal lesions (angiomyolipoma-AML and cysts) are risk factors for arterial hypertension in adult patients with TSC. This study aimed to assess blood pressure, including central blood pressure and arterial damage (early vascular aging-EVA) in children with TSC. Materials and Methods: In a group of 33 pediatric patients with TSC (11.13 ± 4.03 years, 15 boys, 18 girls), we evaluated peripheral and central office blood pressure, 24-h ambulatory blood pressure, and arterial damage: aortic pulse wave velocity (aPWV) [m/s], [Z-score], augmentation index (AIx75HR [%]), common carotid artery intima-media thickness (cIMT) [mm], [Z-score], stiffness of common carotid artery (E-tracking), renal lesions in magnetic resonance and ultrasonography, and selected biochemical parameters. The control group consisted of 33 healthy children (11.23 ± 3.28 years, 15 boys, 18 girls). Results: In TSC group 7 (21.2%) children had arterial hypertension, 27 (81.8%) children had renal angiomyolipomas, 26 (78.8%)-renal cysts, and 4 (12.1%) patients were treated with mTOR inhibitors (2 patients with everolimus and 2 patients with sirolimus) at the moment of evaluation. Children with TSC had higher central systolic blood pressure (AoSBP) (98.63 ± 9.65 vs. 90.45 ± 6.87 [mm Hg], p < 0.001), cIMT (0.42 ± 0.05 vs. 0.39 ± 0.03 [mm], p = 0.011), cIMT Z-score (0.81 ± 1.21 vs. 0.16 ± 0.57, p = 0.007), aPWV (4.78 ± 0.81 vs. 4.25 ± 0.56 [m/s], p = 0.003) and aPWV Z-score (-0.14 ± 1.15 vs. -0.96 ± 0.87, p = 0.002) compared to healthy children, without differences in AIx75HR (8.71 ± 15.90 vs. 5.24 ± 11.12 [%], p = 0.319) and stiffness of common carotid artery. In children with TSC AoSBP correlated positively with serum cystatin C concentration (r = 0.377, p = 0.030) and with maximum diameter of renal cyst (R = 0.419, p = 0.033); mean arterial pressure (MAP) 24 h Z-score correlated with serum cystatin C concentration (R = 0.433, p = 0.013); and aPWV Z-score with daily urinary albumin loss [mg/24 h] (R = 0.412, p = 0.029). Conclusions: Children with tuberous sclerosis complex are at risk of elevated central blood pressure and early vascular aging. In children with TSC, blood pressure and arterial stiffness are related to renal involvement.

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.

Early life exposure to coal mine fire and tobacco smoke affect subclinical vascular function

OBJECTIVE

To evaluate whether vascular health in young children was associated with exposure to a 6-week episode of coal mine fire smoke or environmental tobacco smoke (ETS) in a retrospective cohort study.

METHODS

Three years after a coal mine fire in Victoria, Australia, we investigated the vascular health of children either in utero (n=75) or aged <2 years (postnatal exposure, n=96) at the time of the fire. The outcomes were the carotid intima-media thickness (IMT) and pulse wave velocity (PWV). The mean and peak daily particulate matter <2.5 µm in diameter (PM_2.5) exposures were estimated based on their daily locations throughout the fire period. Multivariable linear regression models were used to test for associations between the fire-related PM_2.5 and outcomes adjusted for relevant covariates including ETS.

RESULTS

In the postnatal-exposure group, each 10 µg/m³ increase in mean PM_2.5 level was independently positively associated with PWV (β=0.116, p=0.028). When these two groups were combined, there was an association between mean PM_2.5 and increased PWV in those children who had ETS exposure (β=0.148, p=0.033) or whose mothers smoked (β=0.151, p=0.011), but not in those not exposed to ETS or maternal smoking.

CONCLUSIONS

Three years after a coal mine fire, infants aged up to 2 years at the time of exposure have increases in vascular stiffness. Although no adverse effects were observed in the in uterus exposure group, further follow-up study is needed to elucidate the long-term effects of coal mine fire smoke exposure.

Upregulation of Transient Receptor Potential Canonical Type 3 Channel via AT1R/TGF-β1/Smad2/3 Induces Atrial Fibrosis in Aging and Spontaneously Hypertensive Rats

Fibroblast proliferation and migration are central in atrial fibrillation (AF) promoting structure remodeling, which is strongly associated with aging and hypertension. Transient receptor potential canonical-3 channel (TRPC3) is a key mediator of cardiac fibrosis and the pathogenesis of AF. Here, we have observed the increased TRPC3 expression that induced atrial fibrosis which possibly is either mediated by the aging process or related to hypertensive progression. In this study, we measured the pathological structure remodeling by H&E staining, Masson staining, and transmission electron microscope (TEM). The protein expression levels of fibrotic biomarkers and TRPC3 were measured by Western blotting with atrial tissues from normotensive Wistar Kyoto rats (WKY 4m-o (4 months old)), old WKY (WKY 24m-o (24 months old)), spontaneously hypertensive rat (SHR 4m-o (4 months old)), and old SHR (SHR 24m-o (24 months old)). To illuminate the molecular mechanism of TRPC3 in atrial fibrosis of aging rats and SHR, we detected the inhibited role of TRPC3 selective blocker ethyl-1-(4-(2,3,3-trichloroacrylamide) phenyl)-5-(trifluoromethyl)-1H-pyrazole-4-carboxylate,pyrazole-3 (Pyr3) on angiotensin II (Ang II) induced fibrosis in neonatal rat atrial fibroblasts. The pathological examination showed that the extracellular matrix (ECM) and collagen fibrils were markedly increased in atrial tissues from aged and hypertensive rats. The protein expressions of fibrotic biomarkers (collagen I, collagen III, and transforming growth factor-β1 (TGF-β1)) were significantly upregulated in atrial tissues from the WKY 24m-o group, SHR 4m-o group, and SHR 24m-o group compared with the WKY 4m-o group. Meanwhile, the expression level of TRPC3 was significantly upregulated in WKY 24m-o and SHR 4m-o atrial tissues compared to WKY 4m-o rats. In isolated and cultured neonatal rat atrial fibroblasts, Ang II induced the atrial fibroblast migration and proliferation and upregulated the expression levels of TRPC3 and fibrotic biomarkers. TRPC3 selected blocker Pyr3 attenuated the migration and proliferation in neonatal rat atrial fibroblasts. Furthermore, Pyr3 significantly alleviated Ang II-induced upregulation of TRPC3, collagen I, collagen III, and TGF-β1 through the molecular mechanism of the TGF-β/Smad2/3 signaling pathway. Similarly, knocking down TRPC3 using short hairpin RNA (shTRPC3) also attenuated Ang II-induced upregulation of TGF-β1. Pyr3 preconditioning decreased Ang II-induced intracellular Ca²⁺ transient amplitude elevation. Furthermore, AT1 receptor was involved in Ang II-induced TRPC3 upregulation. Hence, upregulation of TRPC3 in aging and hypertension is involved in an atrial fibrosis process. Inhibition of TRPC3 contributes to reverse Ang II-induced fibrosis. TRPC3 may be a potential therapeutic target for preventing fibrosis in aging and hypertension.

Feasibility and Normal Ranges of Arterial Intima-Media Thickness and Stiffness in 2-Year-Old Children: A Pilot Study

INTRODUCTION

In adults, noninvasive assessments of vascular function have been established. However, little is known about the applicability and reference values of these techniques among children < 6 years old and none ≤ 2. We aimed to determine the feasibility of conducting noninvasive vascular assessments in 2-year-old children and the normal range of results in this age group.

METHODS

Carotid intima-media thickness (cIMT) and abdominal aorta IMT (aaIMT), pulse wave velocity (PWV), arterial diameter change, stiffness index (β), and distensibility were assessed in 2-year-old children. IMT was assessed using an automatic contour detection.

RESULTS

The proportion of successful measurements was 72% (42/58) with cIMT 64%, aaIMT 67%, and PWV 43%. Average far wall cIMT was 0.51 mm and 0.40 for aaIMT. Mean PWV was 4.15 m/s, with relatively wider range in stiffness index and distensibility. Common carotid arteries had a higher mean distensibility of 4.58%/10 mmHg compared with 2.98%/10 mmHg for the abdominal aorta. The number of data points automatically detected at far wall cIMT was higher than that in aaIMT (left cIMT: 244 ± 13 and right: 240 ± 23 vs. abdominal 185 ± 63, p < 0.001). Better and more consistent quality was achieved for cIMT than aaIMT measurements. PWV measurement was only feasible in cooperative children with efficient distractions.

CONCLUSIONS

Noninvasive methods for early detection of cardiovascular risks were feasible in at least two-thirds of 2-year-old children. Given the greater feasibility and image quality, cIMT is a preferable option for assessing vascular health in young children.

Anthropometric predictors of systolic and diastolic blood pressure considering intersexual differences in a group of selected schoolchildren

OBJECTIVES

Although the association between anthropometric parameters and blood pressure has been established for adults, the relationship for children has not been thoroughly studied in Slovakia. Present study investigates the association between anthropometric parameters and systolic and diastolic blood pressure in the group of randomly selected schoolchildren.

METHODS

Examinations were conducted as a cross-sectional study with 760 schoolchildren from Eastern Slovakia, 381 boys and 379 girls. The blood pressure evaluation included sphygmomanometer technique (seated, 3 times repeated) measurement of systolic and diastolic blood pressure (SBP; DBP). Anthropometric measurements included: body weight, height, circumference of waist, hip and chest, BMI, WHR (waist-hip ratio), fat skinfolds measurement, triceps skinfold, and derivation of body fat percentage. The parents' questionnaires incorporated basic demographic and socioeconomic characteristics of the family, reported BMI of father and mother, and child's birth-weight and birth-length. Statistical analysis included Student's t-test gender differences in measured parameters, partial Pearson's correlations and linear regression model of the impact of body parameters Z-scores on SBP and DPB.

RESULTS

Statistical analysis confirmed gender difference in basic anthropometric parameters. Pearson's correlations revealed highly significant relationship of anthropometric indices to SBP compared to DBP. Correlations of anthropometric parameters with SBP and DPB were more significant for boys compared to girls. Linear regression analysis showed that the highest impact on SBP and DBP had Z-score of BMI, followed by weight and height. Z-score of body weight has statistical impact on SBP and DBP in all group and group of boys (p < 0.001), lower significance was in DBP of girls (p < 0.01). Similar results were obtained for Z-score of height and BMI for SBP and DBP in both total group and group of boys on level p < 0.001. Z-score for BMI and height in DBP has lower statistical significance.

CONCLUSIONS

Linear regression model confirmed higher statistical relationship of SBP and DBP in the group of boys compared to the group of girls. SBP correlations and linear regression model of anthropometric parameters revealed more significant outputs compared to DPB. The results confirmed the fact that we have to consider anthropometric indices in paediatric blood pressure evaluation.

Early Vascular Aging Risk Assessment From Ambulatory Blood Pressure Monitoring: The Early Vascular Aging Ambulatory Score

BACKGROUND

This study compared the diagnostic accuracy of blood pressure (BP) measurement methods, office BP, ambulatory BP monitoring (ABPM), and home BP, in the identification of early vascular aging (EVA) and developed a score to predict the risk of EVA in hypertensive patients.

METHODS

Two-hundred eighty-two consecutive subjects (39.7% male) aged 56.8  ±  15.8 years were included. Office and out-of-office BP measurements including ABPM on a usual working day and 7 days home BP monitoring were performed. Carotid-femoral pulse wave velocity (c-f PWV) was measured in all patients. EVA was defined as c-f PWV values higher than the expected for age average values according to European population data.

RESULTS

In univariate analysis, EVA was significantly correlated with office systolic BP, average 24-hour systolic and diastolic BP, and average 24-hour and office heart rates. The area under the curve for predicting EVA was 0.624 (95% CI 0.551 to 0.697), 0.559 (95% CI 0.484 to 0.635) and 0.565 (95% CI 0.49 to 0.641), for daytime, home, and office systolic BP, respectively. Ambulatory BP variables, age, sex, body mass index, diabetes mellitus (yes/no), and estimated glomerular filtration rate were used to develop a new score for EVA providing a total accuracy of 0.82, 0.84 sensitivity, and 0.78 specificity.

CONCLUSIONS

In conclusion, the new risk score, Early Vascular Aging Ambulatory score, may accurately identify hypertensive patients with EVA using ABPM values and classic cardiovascular risk factors.

The Impact of Being Born Preterm or Small for Gestational Age on Early Vascular Aging in Adolescents

OBJECTIVE

To assess the impact of being born preterm or small for gestational age (SGA) on early vascular aging (EVA) in a cohort of healthy Tyrolean adolescents.

STUDY DESIGN

This study is part of an ongoing clinical trial, EVA Tyrol, a regional cohort study being conducted in western Austria. EVA was assessed in adolescents (mean age, 16 years) by means of carotid-femoral pulse wave velocity (PWV), carotid intima-media thickness (cIMT), and blood pressure measurements. Adolescents were grouped as either term or preterm. Subsequently, being born SGA was taken into consideration in subgroup analysis. Complete data on gestational age and birth weight were available for 930 adolescents.

RESULTS

Systolic blood pressure and diastolic blood pressure were significantly higher in the preterm (mean gestational age, 34.8 ± 2.3 weeks) and appropriate for gestational age (AGA) group than in the term and AGA group (P < .05). This finding remained significant in linear regression analysis after adjustment for covariables in all models. PWV was significantly higher in the term-SGA group than in the term-AGA group (6.67 ± 1.73 m/s vs 6.07 ± 1.09 m/s; P < .05). In the linear regression analysis, this finding remained significant in all models. There were no differences in cIMT between study groups.

CONCLUSION

Being born preterm or SGA might render persons susceptible to EVA. Long-term follow-up of preterm and SGA individuals is warranted to confirm these results.

Reference Intervals of Central Aortic Blood Pressure and Augmentation Index Assessed with an Oscillometric Device in Healthy Children, Adolescents, and Young Adults from Argentina

Age-related reference intervals (RIs) of central (aortic) systolic blood pressure (cSBP) and augmentation index (cAIx) obtained from large healthy population are lacking in Argentina (South America). Aims. To analyze the existence of associations among cSBP and cAIx with demographic, anthropometric, and hemodynamic parameters and to generate percentile curves and RIs adjusted to each level of age and gender and/or body height. cSBP and cAIx were measured in 1038 healthy children, adolescents, and young adults. First, we evaluated if RIs for males and females were necessary using correlation and covariate analysis. Second, mean (M) and standard deviation (SD) age-related equations were obtained for cSBP and cAIx, using parametric regression methods based on fractional polynomials. Third, age specific percentiles curves were generated. Fourth, body height specific percentiles curves were generated using a similar procedure. The obtained equations (considering age as independent variable) for all subjects (cSBP^0.26 and (cAIx + 12.001)^0.5) were as follows: cSBP Mean = 3.0581 + 0.2189 log(Age) − 0.001044Age; cSBP SD = −0.03919 + 0.1535 log(Age) − 0.004564Age; cAIx mean = 9.5226 − 6.1599 log(Age) + 0.1450Age; cAIx SD = 1.3880 − 0.8468 log(Age) + 0.03212Age. This study, performed in Argentinean healthy children, adolescents, and young adults with ages of 5 to 22 years, provides the first RIs and percentile curves of cSBP and cAIx. Additionally, specific body height-related cAIx percentiles are reported for the analyzed population. The RIs and percentiles contribute to the knowledge of arterial dynamic evolution along the normal aging process and the interpretation of data obtained in clinical research and daily clinical practice.

Arterial stiffness in junior high school students: Longitudinal observations

BACKGROUND

Early atherosclerotic change is found even in childhood, and there is an urgent need to clarify the factors causing childhood atherosclerosis and take preventive measures. Early detection of the contributing risk factors is crucial to facilitate preventive measures. Pulse wave velocity (PWV) is a widely used technique for the assessment of atherosclerosis in children.

METHODS

Lifestyle questionnaire, brachio-ankle PWV (baPWV) and anthropometric data were obtained from junior high school students in an urban area of Japan between 2006 and 2008, from seventh to ninth grades.

RESULTS

Mean baPWV increased from 867.4 ± 99.5 m/s to 944.5 ± 117.5 m/s in boys, and from 864.0 ± 99.5 m/s to 923.0 ± 101.3 m/s in girls. Obese students had higher baPWV than non-obese students in both genders across each grade. On logistic regression analysis of ninth grade student data, high baPWV was dependent on systolic blood pressure (SBP), time watching television (TV) and symptoms of depression and anxiety, whereas low baPWV was dependent on time playing video games, light exercise, sleep and indoor play, as well as good friendship and motivation.

CONCLUSION

Systolic blood pressure, time watching TV, and symptoms of depression and anxiety may contribute to arterial stiffness and be related to obesity in junior high school students.

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.

Inverse Relationship between Sleep Duration and Cardio-Ankle Vascular Index in Children

AIM

Poor sleep has been shown to be associated with the development of cardiovascular risk factors, such as obesity, in both adults and children. This study aimed to investigate the relationship between sleep duration and arterial stiffness indices in Japanese children and early adolescents.

METHODS

The data on 102 students (56 males, 46 females; mean age, 11.9±1.8 years) were analyzed. As non-invasive arterial stiffness parameters, the cardio-ankle vascular index (CAVI) and heart-ankle pulse wave velocity (haPWV) were evaluated. Their students' sleep habits (bedtime and wake times on a usual weekday) were investigated using questionnaires, and based on these, their sleep durations were calculated.

RESULTS

The CAVI values in the males and females were 4.8±0.9 and 4.7±0.9 (arbitrary unit), respectively. haPWV values in the males and females were 5.5±0.6 and 5.4±0.6 m/s, respectively. Sleep duration in the males, but not in the females, was negatively correlated with CAVI (r=－0.356) and haPWV (r=－0.356), suggesting that students with short sleep duration could have increased arterial stiffness. After adjusting for confounders, such as age, sex, systolic blood pressure, heart rate, adiposity, and physical fitness, the correlation of sleep duration with CAVI, but not with haPWV, was still significant (partial r=－0.253, p＜0.05).

CONCLUSION

Our findings suggest that shorter sleep duration influences arterial stiffening even in childhood.

ACE2 and the Homolog Collectrin in the Modulation of Nitric Oxide and Oxidative Stress in Blood Pressure Homeostasis and Vascular Injury

SIGNIFICANCE

Hypertension is the leading risk factor causing mortality and morbidity worldwide. Angiotensin (Ang) II, the most active metabolite of the renin-angiotensin system, plays an outstanding role in the pathogenesis of hypertension and vascular injury. Activation of angiotensin converting enzyme 2 (ACE2) has shown to attenuate devastating effects of Ang II in the cardiovascular system by reducing Ang II degradation and increasing Ang-(1-7) generation leading to Mas receptor activation. Recent Advances: Activation of the ACE2/Ang-(1-7)/Mas receptor axis reduces hypertension and improves vascular injury mainly through an increased nitric oxide (NO) bioavailability and decreased reactive oxygen species production. Recent studies reported that shedding of the enzymatically active ectodomain of ACE2 from the cell surface seems to regulate its activity and serves as an interorgan communicator in cardiovascular disease. In addition, collectrin, an ACE2 homolog with no catalytic activity, regulates blood pressure through an NO-dependent mechanism.

CRITICAL ISSUES

Large body of experimental data confirmed sustained beneficial effects of ACE2/Ang-(1-7)/Mas receptor axis activation on hypertension and vascular injury. Experimental studies also suggest that activation of collectrin might be beneficial in hypertension and endothelial dysfunction. Their role in clinical hypertension is unclear as selective and reliable activators of both axes are not yet available.

FUTURE DIRECTIONS

This review will highlight the results of recent research progress that illustrate the role of both ACE and collectrin in the modulation of NO and oxidative stress in blood pressure homeostasis and vascular injury, providing evidence for the potential therapeutic application of ACE2 and collectrin in hypertension and vascular disease. Antioxid. Redox Signal. 26, 645-659.

High Blood Pressure States in Children, Adolescents, and Young Adults Associate Accelerated Vascular Aging, with a Higher Impact in Females' Arterial Properties

The aims of the study were to determine (1) whether the presence of High blood pressure (HBP) states in the youth associate a steeper rate of age-related change in arterial geometrical and wall properties with respect to subjects with no previous cardiovascular risk factor (CRF) exposure, (2) in which parameters and in what magnitude, and (3) the existence of a gender-related difference in the impact of this condition on arterial properties. 300 individuals (mean/range: 15/4-29 years; 133 females) were included. Two groups were assembled: (1) Reference: nonprevious exposure to traditional CRF and (2) HBP: subjects with arterial hypertension and/or elevated blood pressure (BP) levels during the study. Additionally, HBP subjects were separated in BP-related subgroups. Measured parameters were (1) central (aortic) arterial BP and aortic pulse wave analysis parameters, (2) carotid and femoral artery local (pressure-strain elastic modulus) and regional (pulse wave velocity; PWV) stiffness, and (3) arterial diameters and carotid intima-media thickness (CIMT). Age-related changes in these parameters (absolute values and z-scores) were explored by obtaining simple linear regression models for each group. HBP presented a steeper rate of change (accelerated vascular aging; VA) for most of the parameters assessed, mainly in central (aortic) hemodynamics. VA increased as the HBP level got higher. Both males' and females' aging rates were affected by this condition, but females presented a more marked relative age-related increase with HBP exposure. HBP states in the youth gradually associate accelerated VA, with a progressive hemodynamic-structural-functional onset of damage, with females presenting a more marked relative HBP-associated arterial repercussion.

Performance of obesity indices for screening elevated blood pressure in pediatric population: Systematic review and meta-analysis

BACKGROUND

Hypertension is closely related with obesity in pediatric population. Obesity indices were used for screening elevated blood pressure (BP) in children and adolescents. The present study was to perform a meta-analysis to assess the performance of obesity indices, body mass index (BMI), waist circumference (WC), and waist-to-height ratio (WHtR), for identifying elevated BP in children and adolescents.

METHODS

Data sources were PubMed, EMBASE, Web of Science, Cochrane, and SCOPUS up to May 2016. Studies providing measures of diagnostic performance of obesity indices and using age-, sex-, and height-specific BP 95% as reference standard (the definition of United State Fourth Report) were included. We extracted available data on true-positive, false-positive, true-negative, and false-negative to construct a 2 × 2 contingency table and computed the pooled summary statistics for the sensitivities and specificities to estimate the diagnostic performance.

RESULTS

Nine eligible studies that evaluated 25,424 children and adolescents aged 6 to 18 years were included in the meta-analysis. The pooled sensitivities were 42% (BMI), 42% (WC), and 43% (WHtR). The pooled specificities were 80% (BMI), 75% (WC), and 77% (WHtR). The areas under the curve (AUCs) of obesity indices were 0.7780 (BMI), 0.7181 (WC), and 0.6697 (WHtR), respectively. In this meta-analysis, the BP measurements were based on 3 visits in only 1 study. The prevalence of hypertension may be overestimated in these studies.

CONCLUSIONS

The present meta-analysis showed that the performance of obesity indices for identifying elevated BP was poor. Our findings do not support the performance of WC and WHtR is superior to BMI to help identify children with elevated BP.