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Sharma AP, Kirpalani A, Sharma A, Altamirano-Diaz L, Filler G, Norozi K. Impact of the 2022 American Heart Association pediatric ambulatory blood pressure monitoring statement on the diagnosis of hypertension. Pediatr Nephrol 2023; 38:2741-2751. [PMID: 36692729 DOI: 10.1007/s00467-022-05856-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 12/04/2022] [Accepted: 12/05/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND The diagnosis of hypertension and hypertension-induced target organ injury by the 2022 American Heart Association (AHA) ambulatory blood pressure threshold as compared with 2014 AHA and 2016 European Society of Hypertension (ESH) thresholds has not been evaluated. METHODS In a cross-sectional study (n = 291, aged 5-18 years, at a tertiary care outpatient clinic), we compared 2022 AHA with 2014 AHA and ESH thresholds (revised with 2018 adult ESH thresholds where applicable) to diagnose ambulatory hypertension (AH), and detect ambulatory arterial stiffness index (AASI) and left ventricular target organ injury (LVTOI). RESULTS The 2022 AHA threshold diagnosed significantly more AH (53%) than the 2014 AHA (42%, p < 0.01) and ESH (36%, p < 0.001) thresholds. The 2022 AHA threshold demonstrated only a moderate agreement with the 2014 AHA (kappa (k) = 0.77) and ESH (k = 0.66) thresholds to diagnose AH. Adjusted logistic regression analysis found that only the 2022 AHA threshold predicted elevated AASI significantly (odds ratio 2.40, 95% CI 1.09, 5.25, p = 0.02; AUC 0.61, p < 0.01). In those with elevated AASI, more participants had AH by the 2022 AHA threshold (72%) than the 2014 AHA (46%, p = 0.02) and ESH (48%, p = 0.03) thresholds. AH defined by the 2022 AHA threshold continued to maintain higher odds, larger AUC, and higher sensitivity to identify LVTOI than the 2014 AHA and ESH thresholds; however, the difference did not reach a statistically significant level. CONCLUSIONS AH defined by the 2022 AHA threshold diagnoses more children with hypertension and identifies more children with hypertension-induced target organ injury than the 2014 AHA and ESH thresholds. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Ajay P Sharma
- University of Western Ontario, London, ON, Canada.
- Division of Nephrology, Department of Pediatrics, London Health Sciences Centre, London, ON, N6A5W9, Canada.
| | - Amrit Kirpalani
- University of Western Ontario, London, ON, Canada
- Division of Nephrology, Department of Pediatrics, London Health Sciences Centre, London, ON, N6A5W9, Canada
| | - Ajaya Sharma
- University of Western Ontario, London, ON, Canada
| | - Luis Altamirano-Diaz
- University of Western Ontario, London, ON, Canada
- Division of Cardiology, Department of Pediatrics, London Health Sciences Centre, London, ON, Canada
| | - Guido Filler
- University of Western Ontario, London, ON, Canada
- Division of Nephrology, Department of Pediatrics, London Health Sciences Centre, London, ON, N6A5W9, Canada
| | - Kambiz Norozi
- University of Western Ontario, London, ON, Canada
- Division of Cardiology, Department of Pediatrics, London Health Sciences Centre, London, ON, Canada
- Department of Pediatric Cardiology and Intensive Care, Medical School, Hannover, Germany
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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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Sharma AP, Altamirano‐Diaz L, Mohamed Ali M, Stronks K, Kirpalani A, Filler G, Norozi K. Diagnosis of hypertension: Ambulatory pediatric American Heart Association/European Society of Hypertension versus blood pressure load thresholds. J Clin Hypertens (Greenwich) 2021; 23:1947-1956. [PMID: 34668643 PMCID: PMC8630605 DOI: 10.1111/jch.14368] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 09/01/2021] [Accepted: 09/04/2021] [Indexed: 11/27/2022]
Abstract
The agreement between the traditionally-used ambulatory blood pressure (ABP)-load thresholds in children and recently-recommended pediatric American Heart Association (AHA)/European Society of Hypertension (ESH) ABP thresholds for diagnosing ambulatory hypertension (AH), white coat hypertension (WCH), and masked hypertension (MH) has not been evaluated. In this cross-sectional study on 450 outpatient participants, the authors evaluated the agreement between previously used ABP-load 25%, 30%, 40%, 50% thresholds and the AHA/ESH thresholds for diagnosing AH, WCH, and MH. The American Academy of Pediatrics thresholds were used to diagnose office hypertension. The AHA threshold diagnosed ambulatory normotension/hypertension closest to ABP load 50% in 88% (95% CI 0.79, 0.96) participants (k 0.67, 95% CI 0.59, 0.75) and the ESH threshold diagnosed ambulatory normotension/hypertension closest to ABP load 40% in 86% (95% CI 0.77, 0.94) participants (k 0.66, 95% CI 0.59, 0.74). In contrast, the AHA/ESH thresholds had a relatively weaker agreement with ABP load 25%/30%. Therefore, the diagnosis of AH was closest between the AHA threshold and ABP load 50% (difference 3%, 95% CI -2.6%, 8.6%, p = .29) and between the ESH threshold and ABP load 40% (difference 4%, 95% CI -2.1%, 10.1%, p = .19) than between the AHA/ESH and ABP load 25%/30% thresholds. A similar agreement pattern persisted between the AHA/ESH and various ABP load thresholds for diagnosing WCH and MH. The AHA and ESH thresholds diagnosed AH, WCH, and MH closest to ABP load 40%/50% than ABP load 25%/30%. Future outcome-based studies are needed to guide the optimal use of these ABP thresholds in clinical practice.
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Affiliation(s)
- Ajay P. Sharma
- University of Western OntarioLondonOntarioCanada
- Division of NephrologyLondon Health Sciences CentreLondonOntarioCanada
- Department of PediatricsLondon Health Sciences CentreLondonOntarioCanada
| | - Luis Altamirano‐Diaz
- University of Western OntarioLondonOntarioCanada
- Department of PediatricsLondon Health Sciences CentreLondonOntarioCanada
- Division of CardiologyLondon Health Sciences CentreLondonOntarioCanada
| | | | | | - Amrit Kirpalani
- University of Western OntarioLondonOntarioCanada
- Division of NephrologyLondon Health Sciences CentreLondonOntarioCanada
- Department of PediatricsLondon Health Sciences CentreLondonOntarioCanada
| | - Guido Filler
- University of Western OntarioLondonOntarioCanada
- Division of NephrologyLondon Health Sciences CentreLondonOntarioCanada
- Department of PediatricsLondon Health Sciences CentreLondonOntarioCanada
| | - Kambiz Norozi
- University of Western OntarioLondonOntarioCanada
- Department of PediatricsLondon Health Sciences CentreLondonOntarioCanada
- Division of CardiologyLondon Health Sciences CentreLondonOntarioCanada
- Department of Pediatric Cardiology and Intensive careMedical school HannoverHanoverGermany
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Sharma AP, Norozi K, Grattan M, Filler G, Altamirano-Diaz L. Diagnosis of Pediatric Hypertension: European Society of Hypertension-Recommended 24-Hour vs. 24-Hour-Day-Night Ambulatory Blood Pressure Thresholds. Am J Hypertens 2021; 34:198-206. [PMID: 33011756 DOI: 10.1093/ajh/hpaa161] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 07/08/2020] [Accepted: 10/01/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The impact of diagnosing pediatric hypertension based on all three-24-hour, day and night ambulatory blood pressure (ABP) thresholds (combined ABP threshold) vs. conventionally used 24-hour ABP threshold is not known. METHODS In this cross-sectional, retrospective study from a tertiary care outpatient clinic, we evaluated the diagnosis of hypertension based on the 24-hour European Society of Hypertension (ESH) and combined ESH ABP thresholds in untreated children with essential hypertension. The American Academy of Pediatrics (AAP) and Fourth Report thresholds were used to classify office blood pressure (OBP). RESULTS In 159 children, aged 5-18 years, the 24-hour ESH and combined ESH thresholds classified 82% (95th confidence interval (CI) 0.68, 0.97) ABP similarly with the area under the curve (AUC) of 0.86 (95th CI 0.80, 0.91). However, the AUC of the 2 ABP thresholds was significantly higher in the participants with office hypertension than office normotension, with OBP classified by the AAP (AUC 0.93, 95th CI 0.84, 0.98 vs. 0.80, 95th CI 0.71, 0.88) or Fourth Report (AUC 0.93, 95th CI 0.83, 0.98 vs. 0.81, 95th CI 0.73, 0.88) threshold. With OBP classified by the either OBP threshold, the combined ESH threshold diagnosed significantly more masked hypertension (MH) (difference 15%, 95th CI 4.9, 24.7; P = 0.00); however, the diagnosis of white coat hypertension (WCH) by the 2 ABP thresholds did not differ significantly (difference 4%, 95th CI 1.8, 10; P = 0.16). CONCLUSIONS In children with essential hypertension, the 24-hour and combined ESH thresholds have a stronger agreement for diagnosing WCH than MH.
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Affiliation(s)
- Ajay P Sharma
- Department of Paediatrics, University of Western Ontario, London, Ontario, Canada
- Division of Nephrology, University of Western Ontario, London, Ontario, Canada
- Department of Paediatrics, London Health Sciences Centre, London, Ontario, Canada
| | - Kambiz Norozi
- Department of Paediatrics, University of Western Ontario, London, Ontario, Canada
- Department of Paediatrics, London Health Sciences Centre, London, Ontario, Canada
- Division of Cardiology, University of Western Ontario, London, Ontario, Canada
- Department of Paediatric Cardiology, Medical School Hannover, Hannover, Germany
| | - Michael Grattan
- Department of Paediatrics, University of Western Ontario, London, Ontario, Canada
- Department of Paediatrics, London Health Sciences Centre, London, Ontario, Canada
- Division of Cardiology, University of Western Ontario, London, Ontario, Canada
| | - Guido Filler
- Department of Paediatrics, University of Western Ontario, London, Ontario, Canada
- Division of Nephrology, University of Western Ontario, London, Ontario, Canada
- Department of Paediatrics, London Health Sciences Centre, London, Ontario, Canada
| | - Luis Altamirano-Diaz
- Department of Paediatrics, University of Western Ontario, London, Ontario, Canada
- Department of Paediatrics, London Health Sciences Centre, London, Ontario, Canada
- Division of Cardiology, University of Western Ontario, London, Ontario, Canada
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Sharma A, Altamirano-Diaz L, Grattan M, Filler G, Sharma AP. Comparative Analysis of American Heart Association and European Society of Hypertension Ambulatory Blood Pressure Thresholds for Diagnosing Hypertension in Children. Kidney Int Rep 2020; 5:611-617. [PMID: 32405582 PMCID: PMC7210743 DOI: 10.1016/j.ekir.2020.01.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 01/11/2020] [Accepted: 01/20/2020] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION The influence of using 24-hour ambulatory blood pressure (ABP) thresholds recommended by the American Heart Association (AHA) (24-hour mean ABP >95th percentile and ABP load >25%) or the European Society of Hypertension (ESH) (mean 24-hour ABP >95th percentile or >130/80 mm Hg if mean ABP 95th percentile exceeds 130/80 mm Hg) on the diagnosis of pediatric hypertension has been understudied. METHODS In a cross-sectional, retrospective study of 159 children from a tertiary care outpatient clinic, we classified office blood pressure (OBP) as normotension or hypertension based on the OBP thresholds recommended by the American Academy of Pediatrics (AAP) and the fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents (herein referred to as the fourth report) by the National High Blood Pressure Educational Program Working Group on High Blood Pressure in Children and Adolescents separately. Thereafter, we evaluated the agreement between the ambulatory AHA and ESH thresholds for diagnosing normotension, white-coat hypertension (WCH), masked hypertension (MH), and hypertension based on the patient's ABP and OBP hypertension pattern. RESULTS With office hypertension as per the AAP thresholds, the AHA and ESH thresholds classified 85% of subjects similarly into normotension, WCH, MH, and hypertension (κ = 0.78; 95% CI, 0.67-0.89). The agreement between the AHA and ESH thresholds did not change when OBP was reclassified by the fourth-report OBP thresholds (κ = 0.77; 95% CI, 0.65-0.88). With OBP classified by either AAP or fourth-report thresholds, the ESH thresholds diagnosed 6% to 7% more children as hypertensive, whereas the AHA threshold classified 11% more children as normotensive. CONCLUSION The AHA and ESH thresholds have good agreement in classifying OBP. However, the ESH threshold classifies more OBP as hypertensive and the AHA threshold classifies more OBP as normotensive.
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Affiliation(s)
- Ajaya Sharma
- Faculty of Medical Sciences, University of Western Ontario, London, Ontario, Canada
| | - Luis Altamirano-Diaz
- Faculty of Medical Sciences, University of Western Ontario, London, Ontario, Canada
- Division of Cardiology, London Health Sciences Centre, London, Ontario, Canada
- Department of Paediatrics, London Health Sciences Centre, London, Ontario, Canada
| | - Michael Grattan
- Faculty of Medical Sciences, University of Western Ontario, London, Ontario, Canada
- Division of Cardiology, London Health Sciences Centre, London, Ontario, Canada
- Department of Paediatrics, London Health Sciences Centre, London, Ontario, Canada
| | - Guido Filler
- Faculty of Medical Sciences, University of Western Ontario, London, Ontario, Canada
- Department of Paediatrics, London Health Sciences Centre, London, Ontario, Canada
- Division of Nephrology, London Health Sciences Centre, London, Ontario, Canada
| | - Ajay P. Sharma
- Faculty of Medical Sciences, University of Western Ontario, London, Ontario, Canada
- Department of Paediatrics, London Health Sciences Centre, London, Ontario, Canada
- Division of Nephrology, London Health Sciences Centre, London, Ontario, Canada
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Filler G, Torres-Canchala L. Late referrals of pediatric patients with elevated blood pressure. Pediatr Nephrol 2020; 35:721-723. [PMID: 32048002 DOI: 10.1007/s00467-020-04495-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 01/30/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Guido Filler
- Departments of Paediatrics, Medicine and Pathology and Laboratory Medicine, Paediatric Nephrology, Schulich School of Medicine & Dentistry, Children's Hospital, London Health Sciences Centre, University of Western Ontario, 800 Commissioners Road East, London, Ontario, N6A 5W9, Canada.
- Lilibeth Caberto Kidney Clinical Research Unit, London, Ontario, Canada.
| | - Laura Torres-Canchala
- Lilibeth Caberto Kidney Clinical Research Unit, London, Ontario, Canada
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali, Colombia
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Defining and Diagnosing Elevated Blood Pressure in Children and Adolescents. CURRENT CARDIOVASCULAR RISK REPORTS 2016. [DOI: 10.1007/s12170-016-0519-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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