Blood pressure to height ratio: A novel method for detecting hypertension in paediatric age groups

Body Mass Index and Blood Pressure-to-Height Ratio in Predicting Incidence of Hypertension in Serbian Children

BACKGROUND

A new method using blood pressure-to-height ratio for diagnosing elevated blood pressure/hypertension in children has been introduced recently. We aimed to compare blood pressure-to-height ratio (BPHR) and Body Mass Index (BMI) in predicting incidence of hypertension (HTN).

METHODS

The sample consisted of 1133 boys and 1154 girls aged 7-15. We used the following equations for BPHR: systolic BPHR (SBPHR) = SBP (mm Hg)/height (cm) and diastolic BPHR (DBPHR) = DBP (mm Hg)/height (cm). In order to determine the accuracy of SBPHR, DBPHR and BMI as diagnostic tests for elevated blood pressure (elevated BP), we used the receiveroperating characteristic curve analyses.

RESULTS

The area under the curve (AUC) values for BMI ranged from 0.625 to 0.723 with quite low sensitivity rates from 62% to 72.5% and specificities from 58.2% to 67.3% showing a modest ability to identify children with elevated BP and HTN. On the contrary, BPHR showed a great predictive ability to identify elevated BP and HTN with AUC values of 0.836 to 0.949 for SBP and from 0.777 to 0.904 for DBP. Furthermore, the sensitivity ranged from 78.5% to 95.7%, and the specificity from 73.9% to 87.6%.

CONCLUSION

the current study showed that BPHR is an accurate index for detecting elevated BP and HTN in children aged 7 to 15 years and can be used for early screening.

Height-based equations as screening tools for elevated blood pressure in the SAYCARE study

This study evaluated the accuracy of four height-based equations: blood pressure to height ratio (BPHR), modified BPHR (MBPHR), new modified BPHR (NMBPHR), and height-based equations (HBE) for screening elevated BP in children and adolescents in the SAYCARE study. We measured height and BP of 829 children and adolescents from seven South American cities. Receiving operating curves were used to assess formula performance to diagnose elevated BP in comparison to the 2017 clinical guideline. Sensitivity, specificity, and positive and negative predictive values (PPV, NPV) were calculated for the four screening formulas. The diagnostic agreement was evaluated with the kappa coefficient. The HBE equation showed the maximum sensitivity (100%) in children, both for boys and girls, and showed the best performance results, with a very high NPV (>99%) and high PPV (>60%) except for female children (53.8%). In adolescents, the highest sensitivity (100%) was achieved with the NMBPHR for both sexes. Kappa coefficients indicated that HBE had the highest agreement with the gold standard diagnostic method (between 0.70 and 0.75), except for female children (0.57). Simplified methods are friendlier than the percentile gold standard tables. The HBE equation showed better performance than the other formulas in this Latin American pediatric population.

Performance of modified blood pressure-to-height ratio for diagnosis of hypertension in children: The CASPIAN-V study

This study aimed to evaluate the accuracy and performance of modified blood pressure-to-height ratio (MBPHR) for identifying high blood pressure (HBP) in a large population of children. This multicentric cross-sectional study was conducted on a nationally representative sample of 7349 Iranian students aged 7-12 years living in 30 provinces in Iran. High systolic blood pressure and diastolic blood pressure were defined according to the 2017 American Academy of Pediatrics (AAP) guidelines. The BP-to height ratio (BPHR) was calculated as BP (mmHg)/height (cm), MBPHR3 as BP (mmHg)/(height (cm) + 3 (13-age)), and MBPHR7 as BP (mmHg)/(height (cm) + 7 (13-age). The receiver-operating characteristic curve analysis was used to evaluate the performance of these three ratios for identification of HBP in children compared to the 2017 AAP guidelines as the gold standard. Mean age of participants was 12.29 ± 3.15 years and 3736 (50.8%) were girls. The prevalence of HBP was 11.9% (11.5% in boys, 12.3% in girls). The area under the curve (AUC) was higher for MSBPHR3/MDBPHR3 (0.97/0.98) than MSBPHR7/MDBPHR7 (0.96/0.97) and SBPHR/DBPHR (0.96/0.95) for identifying high Systolic and diastolic BP. The optimal cut-off points for MSBPHR3/MDBPH, MSBPHR7/MDBPHR7, and SBPHR/DBPHR were 0.76/0.50, 0.69/0.46, and 0.81/0.52 respectively. Negative predictive value was nearly perfect for three ratios (≥98%). Positive predictive value was higher for MBPHR3 (52.7%) than MBPHR7 (51.0%) and BPHR (39.8%). Overall, MBPHR3 had better performance than MBPHR7 and BPHR for identification of HBP in Iranian children and it may improve early hypertension recognition and control in primary screening.

Using blood pressure height index to define hypertension among secondary school adolescents in southwestern Uganda

Hypertension is the number one risk factor for cardiovascular diseases worldwide and yet its diagnosis among adolescents, based on blood pressure percentiles which are age, height, and sex-specific, is complex. Our study intended to determine the suitability of blood pressure height index in defining adolescent hypertension among secondary school adolescents aged 12-17 years in Mbarara municipality, southwestern Uganda. Our study used data of 485 secondary school adolescents of which 173 were boys. Receiver operating characteristic curve analysis was performed to assess the performance of systolic blood pressure height index (SBPHI) and diastolic blood pressure height index (DBPHI) for screening for adolescent prehypertension and hypertension. The optimal systolic/diastolic thresholds for defining prehypertension were 0.70/0.43 mmHg/cm in boys and 0.76/0.43 in girls. The corresponding values for hypertension were 0.78/0.43 and 0.77/0.48 mmHg/cm, respectively. The negative predictive values were much higher (all ≥ 95%) for prehypertension and hypertension, while the positive predictive value was 100% for hypertension in both sexes. In conclusion, Blood pressure height index is simple and accurate for screening for prehypertension and hypertension in adolescents aged 12-17 years hence can be used for early screening of adolescents at high risk of hypertension but not its diagnosis.

Increased prevalence of hypertensive-level blood pressure using the American Academy of Pediatrics 2017 guidelines: a cross-sectional study in a primary school in Thailand

Background: In 2017, the American Academy of Pediatrics (AAP) launched a new clinical practice guideline for diagnosis of hypertension in children and adolescents. The new cut-off values were 2-3 mmHg lower than those of the previous 2004 guidelines. Aims: This study was conducted to evaluate the effects of the new cut-off values on the prevalence of hypertensive-level blood pressure (BP) in children in a primary school in Bangkok, Thailand. Subjects and methods: BP, weight, height and waist circumference were recorded in 536 school children aged 8-13 years (270 boys, 50.3%) in grades 4-6. For analysis, BP was classified by the two different cut-off values (the 2004 AAP and the 2017 AAP guidelines). Demographic data for the children whose BP was hypertensive according to the 2017 guidelines but not the 2004 guidelines were compared with those of the children with normal BP according to both guidelines. Logistic regression analysis was performed to evaluate the factors associated with hypertensive-level BP. Results: Fifty-eight children (10.8%) had hypertensive-level BP according to the 2017 guidelines but only 37 (6.9%) with the 2004 guidelines. Twenty-one children who would not have had hypertensive-level BP with the 2004 AAP guidelines had greater Z-scores for body mass index and a greater proportion had obesity than the normotensive children. Body mass index was the only independent factor associated with hypertensive-level BP. Conclusions: The prevalence of hypertensive-level BP in children was increased using the 2017 guidelines. Children with hypertensive-level BP using the 2017 AAP guidelines but not the 2004 AAP guidelines had greater BMI Z-scores and a greater proportion were obese than the in the normotensive children. Body mass index was the only independent factor associated with hypertensive-level BP. Abbreviations: AAP: American Academy of Pediatrics; BMI: body mass index; BP: blood pressure; cm: centimeter; DBP: diastolic blood pressure; HT: hypertension; kg: kilograms; m: meter; NHANES: National Health and Nutrition Examination Survey; ROC: receiver operating characteristic curve; SBP: systolic blood pressure; SBPHR: systolic blood pressure-to-height ratio; SD: standard deviation; WC: waist circumference; WHR: waist-to-height ratio.

Relationships between metabolic profile, hypertension and uric acid with cardiometabolic risk in adolescents with abdominal obesity: impact of geodemographic factors on the prevalence of abdominal obesity

Background Association of hyperuricemia, dyslipidemia and high blood pressure (BP) among adolescents with high waist-to-height ratio (WHtR) remains not fully addressed and could represent a new way to diagnose adolescents early with cardiometabolic risk. Objective We aimed to determine abdominal obesity (AO) prevalence and investigate relations between AO, uric acid (UA), lipid profiles, BP and geographical patterns in adolescents. Subjects 577 and 204 Algerian students aged between 10 and 19 years were included in our epidemiological and biochemical studies, respectively. Methods Height, weight, waist circumference (Wc) and hip circumferences, body mass index (BMI) and BP were measured. Fasting blood sampling was performed to measure glycemia, lipid profile, uricemia, insulinemia and leptinemia. The WHtR ≥0.50 was applied for the diagnosis of AO and geodemographics was evaluated. Results The prevalence of AO was 12.13% among all students, 19.17% and 16.39% among students living in urban and plain areas, respectively. The risk of AO may be reduced in rural and mountainous areas. Lipid parameters, UA, insulin and leptin serum concentrations were significantly increased in adolescents with WHtR ≥0.50 compared to those with WHtR <0.50. Cardiometabolic risk was increased with WHtR ≥0.50 and BMI >26. Means of BMI, Wc, BP, and lipid parameters were significantly increased in the fourth quartiles compared to the first quartile of UA. Conclusion Urban areas and plains represent factors contributing to AO and WHtR ≥0.50 may be used as a cut-off point to define risks of high BP, lipid abnormalities and UA serum level in Algerian adolescents.

Performance of User-Friendly Screening Tools for Elevated Blood Pressure in Children

CONTEXT

Hypertension is frequently undiagnosed in children. Several methods have been developed to simplify screening for elevated blood pressure (BP) in children.

OBJECTIVE

to assess the performance of different screening tools in identifying elevated BP in the pediatric population.

DATA SOURCES

Data sources such as PubMed, Embase, Web of Science, Cochrane, and Scopus were searched up to March 2016.

STUDY SELECTION

Studies providing measures of diagnostic performance of screening tools and that used age-, sex-, and height-specific BP percentile as the reference standard were included.

DATA EXTRACTION

Data regarding the population, screening tools used to define elevated BP, and diagnostic criteria of BP were extracted. Available data on true-positive, false-positive, true-negative, and false-negative results were also extracted to construct a 2 × 2 contingency table.

RESULTS

A total of 16 eligible studies that evaluated 366 321 children aged 3 to 18 years were included in the meta-analysis. Nine screening tools were included in this study, in which the BP-to-height ratio, the modified BP-to-height ratio, and tables based on age categories had the highest sensitivities (97-98%) but moderate specificities (71-89%).

LIMITATIONS

Limitations included that BP measurements in most studies were based on 1 visit only and there was heterogeneity between the studies.

CONCLUSIONS

Several user-friendly screening tools could improve the screening of elevated BP in the pediatric population.

Blood pressure-to-height ratio as a screening indicator of elevated blood pressure among children and adolescents in Chongqing, China

We aimed to evaluate the performance of blood pressure-to-height ratio (BPHR) and establish their optimal thresholds for elevated blood pressure (BP) among children aged 6 to 17 years in Chongqing, China. Data were collected from 11 029 children and adolescents aged 6-17 years in 12 schools in Chongqing according to multistage stratified cluster sampling method. The gold standard for elevated BP was defined as systolic blood pressure (SBP) and/or diastolic blood pressure (DBP) ⩾95th percentile for gender, age and height. The diagnostic performance of systolic BPHR (SBPHR) and diastolic BPHR (DBPHR) to screen for elevated BP was evaluated through receiver-operating characteristic curves (including the area under the curve (AUC) and its 95% confidence interval, sensitivity and specificity). The prevalence of elevated BP in children and adolescents in Chongqing was 10.36% by SBP and/or DBP ⩾95th percentile for gender, age and height. The optimal thresholds of SBPHR/DBPHR for identifying elevated BP were 0.86/0.58 for boys and 0.85/0.57 for girls among children aged 6 to 8 years, 0.81/0.53 for boys and 0.80/0.52 for girls among children aged 9 to 11 years and 0.71/0.45 for boys and 0.72/0.47 for girls among adolescents aged 12-17 years, respectively. Across gender and the specified age groups, AUC ranged from 0.82 to 0.88, sensitivity were above 0.94 and the specificities were over 0.7. The positive predictive values ranged from 0.30 to 0.38 and the negative predictive values were ⩾0.99. BPHR, with uniform values across broad age groups (6-8, 9-11 and 12-17 years) for boys and for girls is a simple indicator to screen elevated BP in children and adolescents in Chongqing.

Improving Hypertension Screening in Childhood Using Modified Blood Pressure to Height Ratio

Blood pressure to height ratio (BPHR) has been suggested as a simple method for screening children with hypertension, but its discriminatory ability in young children is not as good as that in older children. Using data of 89,664 Chinese children aged 7 to 11 years, the authors assessed whether modified BPHR (BP:eHT13) was better than BPHR in identifying young children with hypertension. BP:eHT13 was estimated as BP/(height+7×(13-age in years)). Using Youden's index, the thresholds of systolic/diastolic BP:eHT13 for identifying prehypertension and hypertension were 0.67/0.44 and 0.69/0.45, respectively. These proposed thresholds revealed high sensitivity, specificity, negative predictive value, and area under the curve (AUC), ranging from 0.874 to 0.999. In addition, BP:eHT13 showed better AUCs and fewer cutoff points than, if not similar to, two existing BPHR references. BP:eHT13 generally performed better than BPHR in discriminating BP abnormalities in young children and may improve early hypertension recognition and control.

Comparison of different screening methods for blood pressure disorders in children and adolescents

OBJECTIVE

To compare different methods of screening for blood pressure disorders in children and adolescents.

METHOD

A database with 17,083 medical records of patients from a pediatric cardiology clinic was used. After analyzing the inclusion and exclusion criteria, 5,650 were selected. These were divided into two age groups: between 5 and 13 years and between 13 and 18 years. The blood pressure measurement was classified as normal, pre-hypertensive, or hypertensive, consistent with recent guidelines and the selected screening methods. Sensitivity, specificity, and accuracy were then calculated according to gender and age range.

RESULTS

The formulas proposed by Somu and Ardissino's table showed low sensitivity in identifying pre-hypertension in all age groups, whereas the table proposed by Kaelber showed the best results. The ratio between blood pressure and height showed low specificity in the younger age group, but showed good performance in adolescents.

CONCLUSION

Screening tools used for the assessment of blood pressure disorders in children and adolescents may be useful to decrease the current rate of underdiagnosis of this condition. The table proposed by Kaelber showed the best results; however, the ratio between BP and height demonstrated specific advantages, as it does not require tables.

A modified blood pressure to height ratio improves accuracy for hypertension in childhood

BACKGROUND

The blood pressure to height ratio (BP:HT) has been proposed as a simple method for identifying children with elevated BP. This procedure shows good accuracy for the screening of hypertension in adolescents but less so in younger children. Our aim in this study was to modify the BP:HT ratio and determine if this change would increase accuracy when measuring hypertension during childhood.

METHODS

BP levels of 4,327 children (aged 5-12 years) were retrospectively obtained from medical charts. The modified ratio (BT:eHT13) was calculated as: BP/(HT + 7 × (13 - age in years)). Receiver operating characteristic curves were used to estimate cutoff points and the accuracy of the conventional and modified ratio to detect prehypertension and hypertension.

RESULTS

The prevalences of prehypertension and hypertension were 3.91% and 5.44%, respectively. In general, BP:eHT13 showed higher sensitivity (ranging from 0.95 to 1.00) and specificity (ranging from 0.80 to 0.98) in detecting prehypertension, level I hypertension, and level II hypertension than BP:HT (sensitivity ranging from 0.91 to 1.00; specificity ranging from 0.59 to 0.89).

CONCLUSIONS

The modified BP:eHT13 ratio showed better sensitivity and specificity for the screening of BP abnormalities in children aged 5-12 years.

Blood pressure-to-height ratio for screening prehypertension and hypertension in Chinese children

The diagnosis of hypertension in children is complicated because of the multiple age-, sex- and height-specific thresholds. To simplify the process of diagnosis, blood pressure-to-height ratio (BPHR) was employed in this study. Data were obtained from a Chinese national survey conducted in 2010, and 197 191 children aged 7-17 years were included. High normal and elevated blood pressure (BP) were defined according to the National High Blood Pressure Education Program (NHBPEP) Working Group definition. The optimal thresholds were selected by Youden's index. Sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV) and area under the curve (AUC) were assessed for the performance of these thresholds. The systolic and diastolic BPHR thresholds for identifying high normal BP were 0.84/0.55, 0.78/0.50 and 0.75/0.46 for children aged 7-8 years, 9-11 years and 12-17 years, respectively. The corresponding thresholds for identifying elevated BP were 0.87/0.57, 0.81/0.53 and 0.76/0.49, respectively. These proposed thresholds revealed high sensitivity and NPVs, all above 0.96, moderate to high specificity and AUCs, and low PPVs. Our finding suggested the proposed BPHR thresholds were accurate for identifying children without high normal or elevated BP, and could be employed to simplify the procedure of screening prehypertension and hypertension in children.