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Sharma AP, Altamirano-Diaz L, Ali MM, Stronks K, Kirpalani A, Filler G, Norozi K. Ambulatory hypertension diagnosed by 24-h mean ambulatory versus day and night ambulatory blood pressure thresholds in children: a cross-sectional study. Clin Hypertens 2022; 28:34. [PMCID: PMC9664709 DOI: 10.1186/s40885-022-00217-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 06/21/2022] [Indexed: 11/16/2022] Open
Abstract
Abstract
Background
The agreement between the commonly used ambulatory blood pressure (ABP) thresholds to diagnose ambulatory hypertension in children (patient’s 24-h mean ABP classified by 24-h 95th ABP percentile threshold, American Heart Association [AHA] threshold, or patient’s day and night mean ABP classified by day-night 95th ABP percentile thresholds) is not known. We evaluated the agreement among 24-h ABP threshold, AHA threshold, and day-night ABP thresholds to diagnose ambulatory hypertension, white coat hypertension (WCH) and masked hypertension (MH).
Methods
In a cross-sectional study design, we analyzed ABP recordings from 450 participants with suspected hypertension from a tertiary care outpatient hypertension clinic. The American Academy of Pediatrics thresholds were used to diagnose office hypertension.
Results
The 24-h ABP threshold and day-night ABP thresholds classified 19% ABP (95% confidence interval [CI], 0.15–0.23) differently into ambulatory normotension/hypertension (kappa [κ], 0.58; 95% CI, 0.51–0.66). Ambulatory hypertension diagnosed by 24-h ABP threshold in 27% participants (95% CI, 0.22–0.32) was significantly lower than that by day-night ABP thresholds in 44% participants (95% CI, 0.37–0.50; P < 0.001). The AHA threshold had a stronger agreement with 24-h ABP threshold than with day-night ABP thresholds for classifying ABP into ambulatory normotension/hypertension (k 0.94, 95% CI 0.91–0.98 vs. k 0.59, 95% CI 0.52–0.66). The diagnosis of ambulatory hypertension by the AHA threshold (26%; 95% CI, 0.21–0.31) was closer to that by 24-h ABP threshold (27%, P = 0.73) than by day-night ABP thresholds (44%, P < 0.001). Similar agreement pattern persisted among these ABP thresholds for diagnosing WCH and MH.
Conclusions
The 24-h ABP threshold classifies a lower proportion of ABP as ambulatory hypertension than day-night ABP thresholds. The AHA threshold exhibits a stronger agreement with 24-h ABP than with day-night ABP thresholds for diagnosing ambulatory hypertension, WCH and MH. Our findings are relevant for a consistent interpretation of hypertension by these ABP thresholds in clinical practice.
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2
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Larkins NG. Expanding Insights Into the Role of Nocturnal Blood Pressure Variation in Children. Kidney Int Rep 2022; 7:2327-2328. [PMID: 36531888 PMCID: PMC9751669 DOI: 10.1016/j.ekir.2022.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Affiliation(s)
- Nicholas G. Larkins
- Department of Nephrology and Hypertension, Perth Children’s Hospital, Perth, Australia
- Division of Pediatrics, Medical School, University of Western Australia, Perth, Australia
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Nugent JT, Young C, Funaro MC, Jiang K, Saran I, Ghazi L, Wilson FP, Greenberg JH. Prevalence of Secondary Hypertension in Otherwise Healthy Youths with a New Diagnosis of Hypertension: A Meta-Analysis. J Pediatr 2022; 244:30-37.e10. [PMID: 35120981 PMCID: PMC9086113 DOI: 10.1016/j.jpeds.2022.01.047] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 12/26/2021] [Accepted: 01/26/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To estimate the prevalence of secondary hypertension among otherwise healthy children with hypertension diagnosed in the outpatient setting. STUDY DESIGN The MEDLINE, PubMed Central, Embase, Web of Science, and Cochrane Library databases were systematically searched for observational studies reporting the prevalence of secondary hypertension in children who underwent evaluation for hypertension and had no known comorbidities associated with hypertension at the time of diagnosis. Two authors independently extracted the study-specific prevalence of secondary hypertension in children evaluated for hypertension. Prevalence estimates for secondary hypertension were pooled in a random-effects meta-analysis. RESULTS Nineteen prospective studies and 7 retrospective studies including 2575 children with hypertension were analyzed, with a median of 65 participants (range, 9-486) in each study. Studies conducted in primary care or school settings reported a lower prevalence of secondary hypertension (3.7%; 95% CI, 1.2%-7.2%) compared with studies conducted in referral clinics (20.1%; 95% CI, 11.5%-30.3%). When stratified by study setting, there were no significant subgroup differences according to study design, country, participant age range, hypertension definition, blood pressure device, or study quality. Although the studies applied different approaches to diagnosing secondary hypertension, diagnostic evaluations were at least as involved as the limited testing recommended by current guidelines. CONCLUSIONS The low prevalence of secondary hypertension among children with a new diagnosis of hypertension identified on screening reinforces clinical practice guidelines to avoid extensive testing in the primary care setting for secondary causes in most children with hypertension.
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Affiliation(s)
- James T Nugent
- Section of Nephrology, Department of Pediatrics, Yale University School of Medicine, New Haven, CT; Clinical and Translational Research Accelerator, Department of Medicine, Yale University School of Medicine, New Haven, CT.
| | - Chelsea Young
- Section of Nephrology, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Melissa C Funaro
- Harvey Cushing/John Hay Whitney Medical Library, Yale University School of Medicine, New Haven, CT
| | - Kuan Jiang
- Clinical and Translational Research Accelerator, Department of Medicine, Yale University School of Medicine, New Haven, CT
| | - Ishan Saran
- Clinical and Translational Research Accelerator, Department of Medicine, Yale University School of Medicine, New Haven, CT
| | - Lama Ghazi
- Clinical and Translational Research Accelerator, Department of Medicine, Yale University School of Medicine, New Haven, CT
| | - F Perry Wilson
- Clinical and Translational Research Accelerator, Department of Medicine, Yale University School of Medicine, New Haven, CT; Section of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, CT
| | - Jason H Greenberg
- Section of Nephrology, Department of Pediatrics, Yale University School of Medicine, New Haven, CT; Clinical and Translational Research Accelerator, Department of Medicine, Yale University School of Medicine, New Haven, CT
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4
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Chrysaidou K, Chainoglou A, Karava V, Dotis J, Printza N, Stabouli S. Secondary Hypertension in Children and Adolescents: Novel Insights. Curr Hypertens Rev 2020; 16:37-44. [PMID: 31038068 DOI: 10.2174/1573402115666190416152820] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 03/31/2019] [Accepted: 04/01/2019] [Indexed: 12/25/2022]
Abstract
Hypertension is a significant risk factor for cardiovascular morbidity and mortality, not only in adults, but in youths also, as it is associated with long-term negative health effects. The predominant type of hypertension in children is the secondary hypertension, with the chronic kidney disease being the most common cause, however, nowadays, there is a rising incidence of primary hypertension due to the rising incidence of obesity in children. Although office blood pressure has guided patient management for many years, ambulatory blood pressure monitoring provides useful information, facilitates the diagnosis and management of hypertension in children and adolescents, by monitoring treatment and evaluation for secondary causes or specific phenotypes of hypertension. In the field of secondary hypertension, there are numerous studies, which have reported a strong association between different determinants of 24-hour blood pressure profile and the underlying cause. In addition, in children with secondary hypertension, ambulatory blood pressure monitoring parameters offer the unique advantage to identify pediatric low- and high-risk children for target organ damage. Novel insights in the pathogenesis of hypertension, including the role of perinatal factors or new cardiovascular biomarkers, such as fibroblast growth factor 23, need to be further evaluated in the near future.
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Affiliation(s)
- Katerina Chrysaidou
- 1st Department of Pediatrics, Aristotle University Thessaloniki, Hippokratio General Hospital, Thessaloniki, Greece
| | - Athanasia Chainoglou
- 1st Department of Pediatrics, Aristotle University Thessaloniki, Hippokratio General Hospital, Thessaloniki, Greece
| | - Vasiliki Karava
- 1st Department of Pediatrics, Aristotle University Thessaloniki, Hippokratio General Hospital, Thessaloniki, Greece
| | - John Dotis
- 1st Department of Pediatrics, Aristotle University Thessaloniki, Hippokratio General Hospital, Thessaloniki, Greece
| | - Nikoleta Printza
- 1st Department of Pediatrics, Aristotle University Thessaloniki, Hippokratio General Hospital, Thessaloniki, Greece
| | - Stella Stabouli
- 1st Department of Pediatrics, Aristotle University Thessaloniki, Hippokratio General Hospital, Thessaloniki, Greece
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5
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An Update on Hypertension in Children With Type 1 Diabetes. Can J Diabetes 2018; 42:199-204. [DOI: 10.1016/j.jcjd.2018.02.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 02/21/2018] [Indexed: 12/21/2022]
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6
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Lalji R, Tullus K. What's new in paediatric hypertension? Arch Dis Child 2018; 103:96-100. [PMID: 28818842 DOI: 10.1136/archdischild-2016-311662] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 05/31/2017] [Accepted: 06/12/2017] [Indexed: 11/04/2022]
Abstract
Paediatric hypertension predisposes to hypertension and cardiovascular disease in adult life. Despite clear guidelines, there remains a lack of screening. Diagnosis remains challenging given the high rate of false-positive high blood pressure (BP) readings at a single visit; thus, multiple visits are required to confirm the diagnosis. Depending on the normative data sets used, hypertension in overweight and obese children can be underestimated by up to 20%. Specific BP targets are required for subgroups such as adolescents, children with chronic kidney disease (CKD) and type 1 diabetes. High dietary salt intake is a risk factor for cardiovascular disease. Given the rise in processed food consumption, children in developed nations are likely to benefit from salt restriction at a population-based level.
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Affiliation(s)
- Rowena Lalji
- Departmentof Paediatric Nephrology, Great Ormond Street Hospital for Children, London, UK.,Departmentof Paediatric Nephrology, Lady Cilento Children's Hospital, South Brisbane, Queensland, Australia
| | - Kjell Tullus
- Departmentof Paediatric Nephrology, Great Ormond Street Hospital for Children, London, UK
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Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, de Ferranti SD, Dionne JM, Falkner B, Flinn SK, Gidding SS, Goodwin C, Leu MG, Powers ME, Rea C, Samuels J, Simasek M, Thaker VV, Urbina EM. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics 2017; 140:peds.2017-1904. [PMID: 28827377 DOI: 10.1542/peds.2017-1904] [Citation(s) in RCA: 1945] [Impact Index Per Article: 277.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
These pediatric hypertension guidelines are an update to the 2004 "Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents." Significant changes in these guidelines include (1) the replacement of the term "prehypertension" with the term "elevated blood pressure," (2) new normative pediatric blood pressure (BP) tables based on normal-weight children, (3) a simplified screening table for identifying BPs needing further evaluation, (4) a simplified BP classification in adolescents ≥13 years of age that aligns with the forthcoming American Heart Association and American College of Cardiology adult BP guidelines, (5) a more limited recommendation to perform screening BP measurements only at preventive care visits, (6) streamlined recommendations on the initial evaluation and management of abnormal BPs, (7) an expanded role for ambulatory BP monitoring in the diagnosis and management of pediatric hypertension, and (8) revised recommendations on when to perform echocardiography in the evaluation of newly diagnosed hypertensive pediatric patients (generally only before medication initiation), along with a revised definition of left ventricular hypertrophy. These guidelines include 30 Key Action Statements and 27 additional recommendations derived from a comprehensive review of almost 15 000 published articles between January 2004 and July 2016. Each Key Action Statement includes level of evidence, benefit-harm relationship, and strength of recommendation. This clinical practice guideline, endorsed by the American Heart Association, is intended to foster a patient- and family-centered approach to care, reduce unnecessary and costly medical interventions, improve patient diagnoses and outcomes, support implementation, and provide direction for future research.
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Affiliation(s)
- Joseph T Flynn
- Dr. Robert O. Hickman Endowed Chair in Pediatric Nephrology, Division of Nephrology, Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington;
| | - David C Kaelber
- Departments of Pediatrics, Internal Medicine, Population and Quantitative Health Sciences, Center for Clinical Informatics Research and Education, Case Western Reserve University and MetroHealth System, Cleveland, Ohio
| | - Carissa M Baker-Smith
- Division of Pediatric Cardiology, School of Medicine, University of Maryland, Baltimore, Maryland
| | - Douglas Blowey
- Children's Mercy Hospital, University of Missouri-Kansas City and Children's Mercy Integrated Care Solutions, Kansas City, Missouri
| | - Aaron E Carroll
- Department of Pediatrics, School of Medicine, Indiana University, Bloomington, Indiana
| | - Stephen R Daniels
- Department of Pediatrics, School of Medicine, University of Colorado-Denver and Pediatrician in Chief, Children's Hospital Colorado, Aurora, Colorado
| | - Sarah D de Ferranti
- Director, Preventive Cardiology Clinic, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Janis M Dionne
- Division of Nephrology, Department of Pediatrics, University of British Columbia and British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Bonita Falkner
- Departments of Medicine and Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Susan K Flinn
- Consultant, American Academy of Pediatrics, Washington, District of Columbia
| | - Samuel S Gidding
- Cardiology Division Head, Nemours Cardiac Center, Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Celeste Goodwin
- National Pediatric Blood Pressure Awareness Foundation, Prairieville, Louisiana
| | - Michael G Leu
- Departments of Pediatrics and Biomedical Informatics and Medical Education, University of Washington, University of Washington Medicine and Information Technology Services, and Seattle Children's Hospital, Seattle, Washington
| | - Makia E Powers
- Department of Pediatrics, School of Medicine, Morehouse College, Atlanta, Georgia
| | - Corinna Rea
- Associate Director, General Academic Pediatric Fellowship, Staff Physician, Boston's Children's Hospital Primary Care at Longwood, Instructor, Harvard Medical School, Boston, Massachusetts
| | - Joshua Samuels
- Departments of Pediatrics and Internal Medicine, McGovern Medical School, University of Texas, Houston, Texas
| | - Madeline Simasek
- Pediatric Education, University of Pittsburgh Medical Center Shadyside Family Medicine Residency, Clinical Associate Professor of Pediatrics, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, and School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Vidhu V Thaker
- Division of Molecular Genetics, Department of Pediatrics, Columbia University Medical Center, New York, New York; and
| | - Elaine M Urbina
- Preventive Cardiology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
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8
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Harris KC, Benoit G, Dionne J, Feber J, Cloutier L, Zarnke KB, Padwal RS, Rabi DM, Fournier A. Hypertension Canada's 2016 Canadian Hypertension Education Program Guidelines for Blood Pressure Measurement, Diagnosis, and Assessment of Risk of Pediatric Hypertension. Can J Cardiol 2016; 32:589-97. [DOI: 10.1016/j.cjca.2016.02.075] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Revised: 02/29/2016] [Accepted: 02/29/2016] [Indexed: 12/31/2022] Open
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9
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Tainio J, Qvist E, Miettinen J, Hölttä T, Pakarinen M, Jahnukainen T, Jalanko H. Blood pressure profiles 5 to 10 years after transplant in pediatric solid organ recipients. J Clin Hypertens (Greenwich) 2015; 17:154-61. [PMID: 25557075 PMCID: PMC8031723 DOI: 10.1111/jch.12465] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Revised: 10/31/2014] [Accepted: 11/04/2014] [Indexed: 01/20/2023]
Abstract
Arterial hypertension is a major risk factor for cardiovascular disease after solid organ transplantation, emphasizing the need for blood pressure (BP) monitoring. The authors studied 24-hour ambulatory BP monitoring (ABPM) parameters (index, load, dipping) and their predictive value with regard to hypertension as well as correlations with graft function and metabolic parameters such as obesity and dyslipidemias. The ABPM profiles of 111 renal, 29 heart, and 13 liver transplant recipients were retrospectively analyzed 5 to 10 years after transplant (median 5.1 years). The BP profiles among the different transplant groups were similar. The BP index and load were abnormal especially at nighttime and the nocturnal BP dipping was often blunted (in 49% to 83% of the patients). The BP variables were found to be equally valued when assessing hypertension. BP load of 50% instead of 25% seems to be a more adequate cutoff value. The BP variables correlated poorly with the metabolic parameters and kidney function. Antihypertensive medication did not notably change the ABPM profile in renal transplant recipients. Hypertension, including nocturnal hypertension, is present in children receiving solid organ transplant, underlining the importance of use of ABPM in the follow-up of these patients.
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Affiliation(s)
- Juuso Tainio
- Children's HospitalUniversity of Helsinki and Helsinki University Central HospitalHelsinkiFinland
| | - Erik Qvist
- Children's HospitalUniversity of Helsinki and Helsinki University Central HospitalHelsinkiFinland
| | - Jenni Miettinen
- Children's HospitalUniversity of Helsinki and Helsinki University Central HospitalHelsinkiFinland
| | - Tuula Hölttä
- Children's HospitalUniversity of Helsinki and Helsinki University Central HospitalHelsinkiFinland
| | - Mikko Pakarinen
- Children's HospitalUniversity of Helsinki and Helsinki University Central HospitalHelsinkiFinland
| | - Timo Jahnukainen
- Children's HospitalUniversity of Helsinki and Helsinki University Central HospitalHelsinkiFinland
| | - Hannu Jalanko
- Children's HospitalUniversity of Helsinki and Helsinki University Central HospitalHelsinkiFinland
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10
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Leisman D, Meyers M, Schnall J, Chorny N, Frank R, Infante L, Sethna CB. Blood Pressure Variability in Children With Primary vs Secondary Hypertension. J Clin Hypertens (Greenwich) 2014; 16:437-41. [DOI: 10.1111/jch.12322] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Revised: 03/06/2014] [Accepted: 03/10/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Daniel Leisman
- Division of Pediatric Nephrology; Department of Pediatrics; Cohen Children's Medical Center of New York; New Hyde Park NY
| | - Melissa Meyers
- Division of Pediatric Nephrology; Department of Pediatrics; Cohen Children's Medical Center of New York; New Hyde Park NY
| | - Jeremy Schnall
- Division of Pediatric Nephrology; Department of Pediatrics; Cohen Children's Medical Center of New York; New Hyde Park NY
| | - Nataliya Chorny
- Division of Pediatric Nephrology; Department of Pediatrics; Cohen Children's Medical Center of New York; New Hyde Park NY
| | - Rachel Frank
- Division of Pediatric Nephrology; Department of Pediatrics; Cohen Children's Medical Center of New York; New Hyde Park NY
| | - Lulette Infante
- Division of Pediatric Nephrology; Department of Pediatrics; Cohen Children's Medical Center of New York; New Hyde Park NY
| | - Christine B. Sethna
- Division of Pediatric Nephrology; Department of Pediatrics; Cohen Children's Medical Center of New York; New Hyde Park NY
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11
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Abstract
Hypertension is an important public health problem, and increasingly children are being diagnosed with primary hypertension. As the list of secondary causes of hypertension is extensive, pediatric practitioners increasingly need to decide on investigations needed for evaluating children presenting with high blood pressure. The differentiation between primary and secondary hypertension is paramount to understanding this important health issue, since many forms of secondary hypertension require specific treatment. The review evaluates the current available guidelines and practice patterns for evaluating children with elevated blood pressure. The review also aims to provide a framework for cost-effective evaluation strategies for children with elevated blood pressure based on current recommendations and evidence.
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Affiliation(s)
- Gaurav Kapur
- Children's Hospital of Michigan, Wayne State University School of Medicine, Detroit, MI, USA,
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12
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Ruzicka M, Quinn RR, McFarlane P, Hemmelgarn B, Ramesh Prasad GV, Feber J, Nesrallah G, MacKinnon M, Tangri N, McCormick B, Tobe S, Blydt-Hansen TD, Hiremath S. Canadian Society of Nephrology commentary on the 2012 KDIGO clinical practice guideline for the management of blood pressure in CKD. Am J Kidney Dis 2014; 63:869-87. [PMID: 24725980 DOI: 10.1053/j.ajkd.2014.03.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Accepted: 03/06/2014] [Indexed: 12/13/2022]
Abstract
The KDIGO (Kidney Disease: Improving Global Outcomes) 2012 clinical practice guideline for the management of blood pressure (BP) in chronic kidney disease (CKD) provides the structural and evidence base for the Canadian Society of Nephrology (CSN) commentary on this guideline's relevancy and application to the Canadian health care system. While in general agreement, we provide commentary on 13 of the 21 KDIGO guideline statements. Specifically, we agreed that nonpharmacological interventions should play a significant role in the management of hypertension in patients with CKD. We also agreed that the approach to the management of hypertension in elderly patients with CKD should be individualized and take into account comorbid conditions to avoid adverse outcomes from excessive BP lowering. In contrast to KDIGO, the CSN Work Group believes there is insufficient evidence to target a lower BP for nondiabetic CKD patients based on the presence and severity of albuminuria. The CSN Work Group concurs with the Canadian Hypertension Education Program (CHEP) recommendation of a target BP for all non-dialysis-dependent CKD patients without diabetes of ≤140 mm Hg systolic and ≤90 mm Hg diastolic. Similarly, it is our position that in diabetic patients with CKD and normal urinary albumin excretion, raising the threshold for treatment from <130 mm Hg systolic BP to <140 mm Hg systolic BP could increase stroke risk and the risk of worsening kidney disease. The CSN Work Group concurs with the CHEP and the Canadian Diabetic Association recommendation for diabetic patients with CKD with or without albuminuria to continue to be treated to a BP target similar to that of the overall diabetes population, aiming for BP levels < 130/80 mm Hg. Consistent with this, the CSN Work Group endorses a BP target of <130/80 mm Hg for diabetic patients with a kidney transplant. Finally, in the absence of evidence for a lower BP target, the CSN Work Group concurs with the CHEP recommendation to target BP<140/90 mm Hg for nondiabetic patients with a kidney transplant.
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Affiliation(s)
- Marcel Ruzicka
- Division of Nephrology, University of Ottawa, Ottawa, Ontario.
| | - Robert R Quinn
- Department of Medicine, University of Calgary, Calgary, Alberta; Department of Community Health Sciences, University of Calgary, Calgary, Alberta
| | - Phil McFarlane
- Division of Nephrology, St. Michael's Hospital, University of Toronto, Toronto, Ontario
| | - Brenda Hemmelgarn
- Department of Medicine, University of Calgary, Calgary, Alberta; Department of Community Health Sciences, University of Calgary, Calgary, Alberta
| | - G V Ramesh Prasad
- Division of Nephrology, St. Michael's Hospital, University of Toronto, Toronto, Ontario
| | - Janusz Feber
- Division of Nephrology, Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa
| | - Gihad Nesrallah
- The Li Ka Shing Knowledge Institute, Keenan Research Centre, St. Michael's Hospital, University of Toronto, Toronto, Ontario; Division of Nephrology, Humber River Regional Hospital, Toronto, Ontario
| | - Martin MacKinnon
- Division of Nephrology, Saint John Regional Hospital, Saint John, New Brunswick
| | - Navdeep Tangri
- Division of Nephrology, Seven Oaks General Hospital, University of Manitoba, Winnipeg, Manitoba
| | | | - Sheldon Tobe
- Division of Nephrology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario
| | - Tom D Blydt-Hansen
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba
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13
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Karpettas N, Nasothimiou E, Kollias A, Vazeou A, Stergiou GS. Ambulatory and home blood pressure monitoring in children and adolescents: diagnosis of hypertension and assessment of target-organ damage. Hypertens Res 2013; 36:285-92. [PMID: 23344131 DOI: 10.1038/hr.2012.220] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The prevalence of elevated blood pressure in children and adolescents is more common than previously believed and often represents the early onset of essential hypertension, particularly in adolescents. The definition of hypertension in children is based on distribution criteria and normalcy tables that provide blood pressure percentiles for each measurement method (office, ambulatory and home) according to the individual's age, gender and body size. Owing to the white coat and masked hypertension phenomena, ambulatory blood pressure monitoring is indispensable for the diagnosis of hypertension in children. Home blood pressure monitoring in children has been less well studied, and at present, treatment decisions should not be based solely on such measurements. Hypertension-induced preclinical target-organ damage (mainly echocardiographic left ventricular hypertrophy) is not uncommon in children and should be evaluated in all hypertensive children. Other indices of target-organ damage, such as carotid intima-media thickness, pulse wave velocity and microalbuminuria, remain under investigation in pediatric hypertension.
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Affiliation(s)
- Nikos Karpettas
- Hypertension Center, Third University Department of Medicine, Sotiria Hospital, Athens, Greece
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14
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Flynn JT, Urbina EM. Pediatric ambulatory blood pressure monitoring: indications and interpretations. J Clin Hypertens (Greenwich) 2012; 14:372-82. [PMID: 22672091 DOI: 10.1111/j.1751-7176.2012.00655.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The prevalence of hypertension in children and adolescents is increasing, especially in obese and ethnic children. The adverse long-term effects of hypertension beginning in youth are known; therefore, it is important to identify young patients who need intervention. Unfortunately, measuring blood pressure (BP) is difficult due to the variety of techniques available and innate biologic variation in BP levels. Ambulatory BP monitoring may overcome some of the challenges clinicians face when attempting to categorize a young patient's BP levels. In this article, the authors review the use of ambulatory BP monitoring in pediatrics, discuss interpretation of ambulatory BP monitoring, and discuss gaps in knowledge in usage of this technique in the management of pediatric hypertension.
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Affiliation(s)
- Joseph T Flynn
- Division of Nephrology, Seattle Children's Hospital, Seattle, WA 98105, USA.
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15
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JCS Joint Working Group. Guidelines for the Clinical Use of 24 Hour Ambulatory Blood Pressure Monitoring (ABPM) (JCS 2010) - Digest Version -. Circ J 2012; 76:508-19. [DOI: 10.1253/circj.cj-88-0020] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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16
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Flynn JT. Ambulatory blood pressure monitoring in children: imperfect yet essential. Pediatr Nephrol 2011; 26:2089-94. [PMID: 21866381 DOI: 10.1007/s00467-011-1984-9] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2011] [Accepted: 07/21/2011] [Indexed: 11/28/2022]
Abstract
There has been increasing emphasis on hypertension and early cardiovascular disease in the pediatric age group over the past decade as a result of various factors, including the obesity epidemic and publication of new clinical guidelines. A key component of identifying children and adolescents with definite or potential hypertension is proper blood pressure (BP) measurement. While ambulatory blood pressure monitoring (ABPM) offers the potential for improved detection of youths at increased cardiovascular risk, it has not been widely adopted. This commentary highlights the crucial role of ABPM in the context of current trends, while at the same time identifying the current barriers to more widespread application of this technique. Chief among these is the lack of a robust, universally applicable database of pediatric ABPM normative values. Even in the absence of ideal normative data, ABPM can and should be widely applied, and a potential algorithm for such an approach is presented.
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Affiliation(s)
- Joseph T Flynn
- University of Washington School of Medicine, Seattle, WA, USA,
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The definition of daytime and nighttime influences the interpretation of ABPM in children. Pediatr Nephrol 2011; 26:775-81. [PMID: 21327777 DOI: 10.1007/s00467-011-1791-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2010] [Revised: 01/21/2011] [Accepted: 01/26/2011] [Indexed: 12/30/2022]
Abstract
To test if an arbitrary definition of day and night periods that differs to patient-reported awake and sleep periods leads to inaccuracies in interpretation of ambulatory blood pressure monitoring (ABPM). A single-center, retrospective review was performed comparing three different methods to classify day and night periods following a single 24-h ABPM: method A: Patient's record during monitoring; method B: 7:00 am to 11:00 pm day and 11:00 pm to 7:00 am night; method C: 8:00 am to 8:00 pm day and midnight to 6:00 am night. We included 149 studies in 149 children with a mean ± SD age of 13.0 ± 3.4 years. Reported sleep duration was 9.2 ± 1.3 h. Significant differences resulted between three methods for the means of several ambulatory BP parameters including indexed BP values during day, BP load, and nocturnal dipping status. During monitoring [median (range)], 7.5% (0.0-27.5%) readings were misclassified using method B and 0.0% (0.0-20.0%) using method C (p < 0.0001). This misclassification resulted in change of hypertension status for 11.4% (17/149) patients using method B and 9.4% (14/149) patients using method C (p = 0.70). Misclassification of measurements during ABPM can introduce significant errors in its interpretation. The clinical impact of these findings needs further evaluation in larger prospective studies.
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Karpettas N, Kollias A, Vazeou A, Stergiou GS. Office, ambulatory and home blood pressure measurement in children and adolescents. Expert Rev Cardiovasc Ther 2011; 8:1567-78. [PMID: 21090932 DOI: 10.1586/erc.10.148] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
There is an increasing interest in pediatric hypertension, the prevalence of which is rising in parallel with the obesity epidemic. Traditionally the assessment of hypertension in children has relied on office blood pressure (BP) measurements by the physician. However, as in adults, office BP might be misleading in children mainly due to the white coat and masked hypertension phenomena. Thus, out-of-office BP assessment, using ambulatory or home monitoring, has gained ground for the accurate diagnosis of hypertension and decision-making. Ambulatory monitoring is regarded as indispensable for the evaluation of pediatric hypertension. Preliminary data support the usefulness of home monitoring, yet more evidence is needed. Office, ambulatory and home BP normalcy tables providing thresholds for diagnosis have been published and should be used for the assessment of elevated BP in children.
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Affiliation(s)
- Nikos Karpettas
- Hypertension Center, Third University Department of Medicine, Sotiria Hospital, 152 Mesogion Avenue, Athens 11527, Greece
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Sinha R, Dionne J. Ambulatory blood pressure monitoring in children. Indian Pediatr 2011; 48:119-22. [DOI: 10.1007/s13312-011-0042-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
Childhood HTN (hypertension) has become a widely investigated topic within the last decade due to its increasing prevalence. In the present review, we examine new developments and trends that have significantly contributed to aetiology, diagnosis, evaluation and management of childhood HTN. Many recent reports document an increasing prevalence of HTN, mainly essential HTN, in children worldwide. This is probably related to the increase of childhood obesity, although obesity is not the only factor. Evidence has been accumulating to suggest a rather complex interplay between obesity, uric acid level, dietary sodium intake, inflammation, inheritance and other factors, which lead to increased risk of developing HTN in childhood and adulthood. The detection and monitoring of HTN has significantly improved with the use of ABPM (ambulatory blood pressure monitoring), which allows not only for a more accurate classification and staging of HTN, but also for the calculation of more sophisticated parameters such as the AASI (ambulatory arterial stiffness index). Measurement of arterial stiffness enables assessment of arterial dysfunction, which may precede structural vascular changes evaluated by carotid intima media thickness. Sustained HTN eventually leads to end-organ damage [LVH (left ventricular hypertrophy), central nervous system], which in turn increases the risk of cardiovascular morbidity and mortality. New developments in childhood HTN, as outlined in the present review, will hopefully contribute to better screening and management of HTN in children.
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Nocturnal dipping behaviour in normotensive white children and young adults in response to changes in salt intake. J Hypertens 2010; 28:1027-33. [DOI: 10.1097/hjh.0b013e328337854d] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Litwin M, Simonetti GD, Niemirska A, Ruzicka M, Wühl E, Schaefer F, Feber J. Altered cardiovascular rhythmicity in children with white coat and ambulatory hypertension. Pediatr Res 2010; 67:419-23. [PMID: 20032814 DOI: 10.1203/pdr.0b013e3181d00b5b] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Adults with ambulatory hypertension or white coat hypertension (WCH) display abnormal cardiovascular rhythms. We studied cardiovascular rhythms by Fourier analysis of 24-h ambulatory blood pressure (BP) measurement profiles in 129 hypertensive children, 54 children with WCH, and 146 age-, height-, and gender-matched healthy subjects. The day/night mean arterial pressure ratio was lower in hypertensive and patients with WCH compared with controls (1.13 versus 1.16 versus 1.21, respectively; p < 0.0001). Eighty-five percent of controls were dippers compared with 74% of WCH (n.s.) and 64% of patients with ambulatory hypertension (p < 0.0001). The prevalence of 24-h rhythms was similar among the groups, but prevalence of 12-h BP rhythms was increased in hypertensive (67%) and WCH (72%) compared with controls (51%, p < 0.0001). The amplitudes of the 24-, 8-, and 6-h BP rhythms were reduced in hypertensive and WCH compared with controls (p < 0.05). Hypertensive and patients with WCH displayed delayed 24-, 12-, 8-, 6-h acrophases in comparison with controls (p < 0.05). In conclusion, hypertensive children exhibit abnormal cardiovascular rhythmicity compared with controls, especially a higher prevalence of nondipping compared with normotensive children. Abnormalities in patients with WCH are intermediate between healthy children and patients with ambulatory hypertension.
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Blood pressure load, proteinuria and renal function in pre-hypertensive children. Pediatr Nephrol 2009; 24:823-31. [PMID: 19096881 DOI: 10.1007/s00467-008-1077-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2008] [Revised: 11/07/2008] [Accepted: 11/10/2008] [Indexed: 01/18/2023]
Abstract
It is as yet unclear whether blood pressure load (BPL) can affect renal function in pre-hypertensive children. We have studied 250 children, with a mean age of 9.12 +/- 3.28 years, with the aim of assessing if pre-hypertension in children can indeed affect renal function. The study cohort consisted of 146 children with pre-hypertension (group P) and a control group of 104 children with normal blood pressure (group C). All children were tested for orthostatic proteinuria, an exclusion criterion, glomerular filtration rate (GFR), and proteinuria, and ambulatory blood pressure monitoring was performed. Based on the BPL, group P was further subdivided into group P1 (BPL <or= 40%, low BPL) and group P2 (BPL > 40%, high BPL). We found that GFR was reduced in pre-hypertensive children (90.74 +/- 48.69 vs. 110.32 +/- 20.30 ml/min per 1.73 m(2), p < 0.0001) and that proteinuria was increased (145.36 +/- 110.91 vs. 66.84 +/- 42.94 mg/m(2) per 24 h; p < 0.0001). However, mean values were still within normal limits. A comparison of the group with high BPL and that with low BPL revealed that the former had relatively reduced GFR (79.15 +/- 42.04 vs. 96.78 +/- 51.20 ml/min per 1.73 m(2); p < 0.006) and increased proteinuria (198.29 +/- 142.17 vs. 118.31 +/- 80.07 mg/m(2) per 24 h; p < 0.036). In comparison to the reference values of the normal population, the GFR was reduced and proteinuria was increased in the group with high BPL. Based on our results, pre-hypertension in children with high BPL seems to be associated with reduced GFR and increased proteinuria. A reasonable doubt remains that the patients with higher proteinuria and larger reduction of GFR may harbor an as yet unknown subclinical renal condition responsible for the onset of pre-hypertension. Therefore, children with even mildly elevated BP are at risk of developing renal damage and should change their lifestyle to prevent further increases in BP.
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Abstract
Hypertension is a common and serious complication after renal transplantation. It is an important risk factor for graft loss and morbidity and mortality of transplanted children. The etiology of posttransplant hypertension is multifactorial: native kidneys, immunosuppressive therapy, renal-graft artery stenosis, and chronic allograft nephropathy are the most common causes. Blood pressure (BP) in transplanted children should be measured not only by casual BP (CBP) measurement but also regularly by ambulatory BP monitoring (ABPM). The prevalence of posttransplant hypertension ranges between 60% and 90% depending on the method of BP measurement and definition. Left ventricular hypertrophy is a frequent type of end-organ damage in hypertensive children after transplantation (50-80%). All classes of antihypertensive drugs can be used in the treatment of posttransplant hypertension. Hypertension control in transplanted children is poor; only 20-50% of treated children reach normal BP. The reason for this poor control seems to be inadequate antihypertensive therapy, which can be improved by increasing the number of antihypertensive drugs. Improved hypertension control leads to improved long-term graft and patient survival in adults. In children, there is a great potential for antihypertensive treatment that could also result in improved graft and patient survival.
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Affiliation(s)
- Tomáš Seeman
- Department of Pediatrics and Transplantation Center University, University Hospital Motol, Charles University Prague, Second School of Medicine, V Úvalu 84, 15006 Prague, Czech Republic
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Ambulatory blood pressure monitoring: a versatile tool for evaluating and managing hypertension in children. Pediatr Nephrol 2008; 23:1399-408. [PMID: 18297314 DOI: 10.1007/s00467-008-0766-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2007] [Revised: 01/08/2008] [Accepted: 01/10/2008] [Indexed: 10/22/2022]
Abstract
In recent years, pediatric practitioners have increasingly used ambulatory blood pressure (ABP) monitoring for evaluating blood pressure (BP) abnormalities in children. ABP monitoring in adults is superior to casual BP measurements for predicting cardiovascular morbidity and mortality, and whereas the association with target-organ damage in children is not as definitive, early evidence does seem to parallel the adult data. In addition to confirming hypertension at diagnosis, ABP monitoring may be useful for identifying isolated nocturnal hypertension, characterizing BP patterns, and assessing response to therapeutic interventions. This article reviews current evidence supporting the use of ABP monitoring in children and discusses limitations in our understanding of this technology, specifically focusing on indications for its use and interpretation of the large quantity of data obtained by ABP monitoring.
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Urbina E, Alpert B, Flynn J, Hayman L, Harshfield GA, Jacobson M, Mahoney L, McCrindle B, Mietus-Snyder M, Steinberger J, Daniels S. Ambulatory blood pressure monitoring in children and adolescents: recommendations for standard assessment: a scientific statement from the American Heart Association Atherosclerosis, Hypertension, and Obesity in Youth Committee of the council on cardiovascular disease in the young and the council for high blood pressure research. Hypertension 2008; 52:433-51. [PMID: 18678786 DOI: 10.1161/hypertensionaha.108.190329] [Citation(s) in RCA: 355] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Elaine Urbina
- American Heart Association, Public Information, 7272 Greenville Ave, Dallas, TX75231-4596, USA
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Díaz LN, Garin EH. Comparison of ambulatory blood pressure and Task Force criteria to identify pediatric hypertension. Pediatr Nephrol 2007; 22:554-8. [PMID: 17123115 DOI: 10.1007/s00467-006-0372-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2006] [Revised: 10/19/2006] [Accepted: 10/23/2006] [Indexed: 10/23/2022]
Abstract
The aim of this study was to assess the level of agreement between central European ambulatory blood pressure monitoring (ABPM) and American Task Force (TF) criteria when applied to blood pressure (BP) measurements collected by ABPM to evaluate patients with hypertension. In 169 patients, we applied both sets of criteria and calculated mean daytime and nighttime BP and daytime BP loads. The frequency of hypertension for daytime systolic BP was significantly higher when TF criteria were used (p <or= 0.001). However, the frequency of hypertension for nighttime systolic BP was significantly increased when ABPM criteria were applied (p <or= 0.01). Therefore, with daytime ABPM measurements, hypertension was overdiagnosed with TF criteria, while nighttime hypertension was underdiagnosed using TF criteria. In contrast with previous reports, 40% of our patients with essential hypertension showed absence of nighttime dipping, regardless of the criteria used. The number of hypertensive patients was significantly higher using ABPM compared to TF criteria when patients with BP load >or=50% were evaluated (p <or= 0.01). Therefore, current recommendations for ABPM use in children such as to define white coat hypertension or as a screening tool to differentiate between primary and secondary hypertension need to be validated using yet to be produced normative ABPM criteria in American children.
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Affiliation(s)
- Leila N Díaz
- Division of Nephrology, Department of Pediatrics, College of Medicine, University of Florida, P.O. Box 100296, Gainesville, FL 32610, USA
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Abstract
PURPOSE OF REVIEW Ambulatory blood pressure monitoring is a useful tool for the evaluation and management of hypertension in children and adolescents. This review provides a basic overview of ambulatory blood pressure monitoring and summarizes the most recent available knowledge regarding its use in the pediatric population. RECENT FINDINGS Evaluation and validation of ambulatory blood pressure monitoring equipment in children remains limited, although advances in the interpretation of results for this age group have been reported specifically in the area of circadian (24 h) and ultradian (<24 h) variability. Blood pressure is a dynamic phenomenon that varies not only with time but also with changing patient and environmental circumstances. Growing evidence regarding conditions identified when this variability is considered, specifically white coat and masked hypertension, suggests that office blood pressure measurement may not be a sufficient screening test for hypertension-related target-organ damage. SUMMARY Information regarding ambulatory blood pressure monitoring use in children is increasing, although due to its limitations and expense, it remains a tool primarily utilized by the pediatric sub-specialist.
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Affiliation(s)
- Karen L McNiece
- Department of Pediatrics, Division of Pediatric Nephrology and Hypertension, University of Texas - Houston, School of Medicine, Houston, Texas 77057, USA.
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