Ambulatory and home blood pressure monitoring in children and adolescents: diagnosis of hypertension and assessment of target-organ damage

Neutrophil to Lymphocyte Ratio Is Increased and Associated With Left Ventricular Diastolic Function in Newly Diagnosed Essential Hypertension Children

Aim: Hypertension is associated with cardiac structural and functional changes, including left ventricular hypertrophy (LVH) and LV systolic dysfunction diastolic dysfunction. Neutrophil-to-lymphocyte ratio (NLR) is a novel inflammatory biomarker associated with cardiovascular diseases. The current study aimed to evaluate NLR in children with newly diagnosed essential hypertension and its relationship between blood pressure and cardiac changes. Methods and Subjects: Sixty-five children with newly diagnosed essential hypertension and 54 healthy children were included. Clinical characteristics, blood cell counts, and biochemical parameters were collected. LVH was assessed by calculation of LV mass index (LVMI), and LV systolic function was evaluated by measuring LV ejection fraction and fractional shortening. LV diastolic function was primarily assessed with E/E' ratio by Doppler and echocardiography. Results: The hypertension children had significantly higher LVMI and E/E' ratio than the controls, whereas there was no difference in LV systolic function between the two groups. The NLR was significantly higher in the hypertension group than the control group. Moreover, NLR was positively correlated with systolic blood pressure (SBP) and diastolic blood pressure (DBP) levels in the hypertension group. Additionally, a significantly positive correlation between NLR and E/E' ratio was found in the hypertension group. However, NLR was not related to LVH and LV systolic function indicators in hypertension children. Conclusion: NLR is elevated in hypertension children, and it is associated positively with office blood pressure levels. Moreover, NLR may help assess LV diastolic function in hypertension children.

Home Blood Pressure Monitoring in Children and Adolescents: Systematic Review of Evidence on Clinical Utility

PURPOSE OF REVIEW

For the accurate diagnosis and management of hypertension, out-of-office blood pressure evaluation using ambulatory (ABPM) or home monitoring (HBPM) is currently recommended. In children, there is considerable evidence on the clinical utility of ABPM, whereas the evidence on HBPM is limited. This systematic review presents (i) the benefits of HBPM in children; (ii) the evidence on normal range, diagnostic accuracy, and relationship with preclinical organ damage; and (iii) guidance for devices, monitoring schedule, and interpretation.

RECENT FINDINGS

HBPM is a useful adjunct to the conventional office measurements for the evaluation of children with suspected or treated hypertension. HBPM is feasible in children and has good reproducibility, diagnostic accuracy and acceptability by users, and relatively low cost. Thus, it has greater potential for widespread and long-term use than ABPM, which is more expensive and often not available or not tolerated. Automated monitors that have been clinically validated specifically in children should be used with appropriate cuff size. HBPM for 7 days (minimum 3) with duplicate morning and evening measurements (minimum 12 readings) should be performed in children with suspected or treated hypertension before each office visit. Until more data become available, in case of diagnostic disagreement between office blood pressure and HBPM, treatment decisions should be based on ABPM. HBPM is clinically useful in children with hypertension. More research is needed on its clinical application, and more automated devices need to be clinically validated in this population.

Health-related quality of life in paediatric arterial hypertension: a cross-sectional study

Background

The prevalence of paediatric hypertension is increasing worldwide, especially due to the childhood obesity epidemic, and is an important public-health concern. While the Health-Related Quality of Life (HRQoL) was already shown to be impaired in the adult hypertensive population, a scarcity of data still exists on HRQoL in paediatric hypertensive patients. Our purpose was thus to assess the HRQoL of children and adolescents with arterial hypertension, using self- and proxy-reports, and to determine the correlations between child and parent questionnaire scores.

Methods

The Paediatric Quality of Life Inventory™ 4.0 Generic Core Scales were administered via post to children and adolescents, aged 5-18 years, with primary or secondary arterial hypertension and parents as proxy-reports. Patients were recruited from a paediatric nephrology unit in a tertiary hospital, using an out-patient clinic visit registry. Healthy school children and adolescents from a local primary school, aged 6 to 15 years, and their parents formed the control group. HRQoL group comparisons were calculated with independent samples t-test and child-parent correlations with the Pearson’s r correlation coefficient.

Results

In total we recruited 139 patient and 199 control group participants as self- and proxy-reports. Scores from self- as well as proxy-reports indicated a significantly lower overall HRQoL in the paediatric hypertensive population (95% CI for mean score difference: − 11.02, − 2.86 for self- and − 10.28, − 2.67 for proxy-reports; p = .001). In self-reports, lower physical (95% CI: -13.95, − 4.89; p = <.001), emotional (95% CI: -12.96, − 2.38; p = .005), school (95% CI: -11.30, − 0.42; p = .035), and psychosocial functioning scores were observed (95% CI: -10.34, − 1.89; p = .005). Parent proxy-reports were lower in physical (95% CI: -14.31, − 5.39; p = <.001), emotional (95% CI: -12.39, − 2.60; p = .003) and psychosocial scores (95% CI: -9.36, − 1.34; p = .009). Pearson’s r values ranged between 0.62 to 0.79 in patient and 0.56 to 0.80 in control sample (p < .001). Interestingly, hypertensive children reported lower social functioning scores than hypertensive adolescents (p < .001).

Conclusions

This cross-sectional study gives insight into the detrimental impact of hypertension on children’s and adolescents HRQoL, which may inform public health experts. Furthermore, it shows that clinicians should aim to improve patients’ physical and psychosocial well-being throughout their development.

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

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

Non-dipping blood pressure patterns and arterial stiffness parameters in patients with Behcet's disease

Behcet's disease is a multisystemic vasculitis involving veins and arteries of various sizes. Non-dipping status, augmentation index and pulse wave velocity are important determinants of cardiovascular mortality and morbidity. We investigated the non-dipping status and arterial stiffness in patients with Behcet's disease. In this cross-sectional study, we examined the vascular parameters of 96 patients with Behcet's disease (53% female) and 60 age- and sex-matched control subjects. The non-dipping status and arterial distensibility were assessed using a Mobil-O-Graph Arteriograph, an automatic oscillometric device. In total, 65.6% of 96 patients were systolic non-dippers, and 34.4% exhibited high augmentation indices. Ten percent of the control subjects were systolic non-dippers, and 11.7% exhibited high augmentation indices. Nocturnal decreases in systolic blood pressure correlated with central systolic blood pressure and diastolic blood pressure, as well as nocturnal decreases in diastolic blood pressure. Furthermore, non-dipper patients with Behcet's disease exhibited higher nocturnal cardiac outputs than did dipper patients with Behcet's disease. Augmentation index correlated negatively with C-reactive protein and correlated positively with both 24 h and nocturnal peripheral resistance, as well as 24 h pulse wave velocity. The patients with high augmentation indices exhibited lower creatinine clearance, as well as lower nocturnal cardiac outputs, higher 24 h peripheral resistance and higher 24 h pulse wave velocities. Non-dipping status and arterial stiffness may exacerbate the harmful cardiovascular effects of the other. In addition to conventional risk factors, non-dipping status and arterial stiffness should be examined during the follow-up evaluations of patients with Behcet's disease.

Strengths and limitations of current pediatric blood pressure nomograms: a global overview with a special emphasis on regional differences in neonates and infants

The availability of robust nomograms is essential for the correct evaluation of blood pressure (BP) values in children. A literature search was conducted by accessing the National Library of Medicine by using the keywords BP, pediatric and reference values/nomograms. A total of 43 studies that evaluated pediatric BP nomograms were included in this review. Despite the accuracy of the latest studies, many numerical and methodological limitations still remain. The numerical limitations include the paucity of data for neonates/infants and for some geographic areas (Africa/South America/East Europe/Asia) and ethnicities. Furthermore, the data on ambulatory BP and response to exercise are extremely limited, and the criteria for stress-test interruption are lacking. There was heterogeneity in the methodologies employed to perform the measurements, in the inclusion/exclusion criteria (often not reported), in the data normalization and the data expression (Z-scores/percentiles/mean values). Although most studies adjusted the measurements for age and/or height, the classification by specific age/height subgroups varied. Gender differences were generally considered, whereas other confounders (that is, ethnicity/geographic area/environment) were seldom evaluated. As a result, nomograms were heterogeneous, and when comparable, at times showed widely different confidence intervals. These differences are most likely because of both methodological limitations and differences among the populations studied. Some robust nomograms exist (particularly those from the USA); however, it has been demonstrated that if adopted in other countries/continents, they may generate an unpredictable bias in the evaluation of BP values in children. Actual pediatric BP nomograms present consistent limitations that affect the evaluation of BP in children. Comprehensive nomograms, which are based on a large population of healthy children (including neonates/infants) and use standardized methodology, are warranted for every country/region.

Blood Pressure, Heart Rate, and CNS Stimulant Medication Use in Children with and without ADHD: Analysis of NHANES Data

It is estimated that 2-3% of children in the US have hypertension (HTN) and 8% of children ages 4-17 carry the diagnosis of attention-deficit hyperactivity disorder (ADHD). The prevalence of HTN and cardiovascular (CV) risk factors in children with ADHD on CNS stimulant treatment (stimulants) compared to no treatment and compared to their healthy counterparts is not well described. Using National Health and Nutrition Survey data, we examined demographic, blood pressure (BP) and CV risk factors of 4,907 children aged 12-18 years with and without the diagnosis of ADHD, and further examined the CV risk in a subgroup of ADHD patients on stimulants. Three hundred eighty-three (10.7%) children were reported to have ADHD, of whom 111 (3.4%) were on stimulants. Children with ADHD on stimulants were significantly younger, male, and white compared to those with ADHD not on medication and those without ADHD. Body mass index (BMI), eGFR, cholesterol, the prevalence of albuminuria, and poverty were not significantly different between the three groups. One hundred sixty (2.7%) had BP in the hypertensive and 637 (12.4%) in the pre-hypertensive range. The prevalence of elevated BP (HTN and/or pre-HTN range) was not different between children with ADHD on stimulants compared to ADHD without medication and those without ADHD. Heart rate (HR) was significantly higher in the ADHD group on stimulants vs. the groups ADHD on no stimulants and without ADHD. When the relationship between stimulants and the risk of abnormal BP was examined, there was a significant interaction between having BP in the HTN range and sex. After adjusting for BMI, race, and age, females with ADHD on stimulants tended to be older and had significantly more BP in the hypertensive range. On the other hand, males were more likely to be of a white race and older, but not hypertensive. Children with ADHD on stimulants have significantly higher HR than children with ADHD on no stimulants and children without ADHD. On the other hand, the prevalence of abnormal BP classification is comparable between the three groups.