Cost-effectiveness of ambulatory blood pressure monitoring in the initial evaluation of hypertension in children

Blood pressure in girls with central precocious puberty receiving GnRH analogue therapy

OBJECTIVES

Case reports show hypertension in children treated with GnRH analogues for central precocious puberty (CPP). However, relevant data on blood pressure are scarce. We aimed to evaluate blood pressure (BP) among girls with idiopathic CPP and early-onset puberty before and during GnRH analogue therapy; and to examine associations of blood pressure with clinical parameters.

METHODS

For this retrospective longitudinal cohort study, demographic, anthropometric, clinical, and laboratory data were collected from electronic files. The study group included 112 girls with idiopathic CPP or early-onset puberty followed in a tertiary pediatric endocrinology institute, and a control group of 37 healthy pre-pubertal girls. The main outcome measures were BP percentile, before, and during treatment with GnRH analogue.

RESULTS

At baseline, similar proportions of the study and control groups had BP values>90th percentile: 64 (53 %) and 17 (46 %), respectively (p=0.57). The mean systolic and diastolic BP percentiles measured under treatment remained unchanged. In the study group, baseline BP>90th percentile compared to normal baseline BP was associated with lower birthweight and a higher body mass index-standard deviation score: 2,821 ± 622 vs. 3,108 ± 485 g and 1.0 ± 0.7 vs. 0.70 ± 0.8, respectively, p=0.01 for both.

CONCLUSIONS

GnRH analogue therapy for precocious or early puberty was not associated with increased blood pressure. The stability of mean blood pressure percentile during treatment is reassuring.

Waist-to-height-ratio is associated with sustained hypertension in children and adolescents with high office blood pressure

Background

Waist-to-height-ratio (WHtR) has been proposed as another indicator for cardiometabolic risk factors including hypertension. Normally, hypertension can be diagnosed in the office setting by detecting high blood pressure for three occasions. However, patients with high office blood pressure may not exhibit high blood pressure outside the office. Ambulatory blood pressure monitoring (ABPM) is a procedure to measure blood pressure over 24-h. Sustained hypertension is characterized as hypertension detected by both office measurement and ABPM. This study aimed to evaluate the performance of WHtR in the diagnosis of sustained hypertension in patients with high office blood pressure.

Materials and methods

Demographic data, height, body weight, body mass index (BMI), and waist circumference were retrospectively reviewed in children and adolescents who underwent ABPM due to persistently high office blood pressure. Patients were separated into two groups: a sustained hypertension group and a normal ABPM group. BMI was adjusted to z-score using the WHO Anthroplus software. WHtR was calculated by the formula: waist circumference (cm)/height (m). The performances of different parameters were analyzed using the receiver operating characteristic (ROC) curve and multivariate logistic regression.

Results

Sixty patients (63% male) with a mean age of 12.9 ± 3.7 years had persistently high office blood pressure. Twenty-nine (48.3%) had high ambulatory blood pressure parameters so-called "sustained hypertension." The sustained hypertension group had a higher mean BMI z-score (2.32 vs. 1.31, p = 0.01) and a higher mean WHtR (57.7 vs. 49.2 cm/m, p < 0.001) than those of the normal ABPM group. For the diagnosis of sustained hypertension, the ROC analysis revealed that WHtR had a greater area under the ROC curve (AUC) than that of BMI z-score (0.772 vs. 0.723). WHtR remained associated with sustained hypertension (OR 1.2, 95% CI 1.022-1.408, p = 0.026) after adjusting for age, gender, and BMI z-score.

Conclusions

Apart from being a more user-friendly metric, WHtR tended to outperform BMI z-score in predicting sustained hypertension in children and adolescents with persistently high office blood pressure.

Ambulatory blood pressure monitoring in children: A retrospective single-center study

OBJECTIVES

(1) Compare 24-hour ambulatory blood pressure monitoring (ABPM) diagnoses in a pediatric population with the new 2022 guidelines to the original diagnoses with the 2014 guidelines. (2) Determine whether findings of hypertension from ABPM could be predicted from prior patient data. (3) Determine whether ABPM readings could predict left ventricular mass index (LVMI) in patients who obtained an echocardiogram (ECHO).

STUDY DESIGN

Single-center retrospective study on patients referred to Pediatric Nephrology Clinic for evaluation of elevated blood pressure who underwent ABPM from 2015 to 2018. Predictions of hypertension were obtained using a logistic regression model, and predictions of LVMI were performed using regression models including (a) the wake systolic and diastolic BP indices, or (b) additionally including the standard deviation (SD) of wake SBP and DBP.

RESULTS

With the change in 2022 to new ABPM guidelines from the AHA, comparing the old and new guidelines led to 70% of previous pre-hypertensive diagnoses now meeting criteria for diagnosis of hypertension, and a rise from 21% of the ABPMs meeting criteria for hypertension to 51% now meeting criteria. In a logistic regression model, prior patient data were not predictive of a diagnosis of hypertension from ABPM (Nagelkerke's R ² = 0.04). Among the individual variables studied, none were statistically significant. For prediction of LVMI, the SD of wake SBP and DBP were significantly associated with increased LVMI, but the wake SBP and DBP indices were not.

CONCLUSIONS

In our patient population, the new ABPM guidelines led to a significant increase in diagnoses of hypertension. Prior patient data was not sufficient to predict a diagnosis of hypertension by ABPM, supporting the need for evaluation by ABPM as the gold standard. Our analysis of the relationship between ABPM readings and LVMI supports the hypothesis that BP variability contributes to increased LVMI. These data are consistent with growing evidence in the adult literature that BP variability detected by ABPM is associated with left-ventricular hypertrophy.

Hypertension in Children and Young Adults

Primary hypertension (PH) is most common during adolescence with increasing prevalence globally, alongside the epidemic of obesity. Unlike in adults, there are no data on children with uncontrolled hypertension and their future risk of hard cardiovascular and cerebrovascular outcomes. However, hypertension in childhood is linked to hypertensive-mediated organ damage (HMOD) which is often reversible if treated appropriately. Despite differing guidelines regarding the threshold for defining hypertension, there is consensus that early recognition and prompt management with lifestyle modification escalating to antihypertensive medication is required to ameliorate adverse outcomes. Unfortunately, many unknowns remain regarding pathophysiology and optimum treatment of childhood hypertension.

Demographics of childhood hypertension in the UK: a report from the Southeast England

We aimed to describe hypertensive phenotype and demographic characteristics in children and adolescents referred to our paediatric hypertension service. We compared age, ethnicity and BMI in primary hypertension (PH) compared to those with secondary hypertension (SH) and white coat hypertension (WCH). Demographic and anthropometric data were collected for children and adolescents up to age 18 referred to our service for evaluation of suspected hypertension over a 6 year period. Office blood pressure (BP) and out of office BP were performed. Patients were categorised as normotensive (normal office and out of office BP), WCH (abnormal office BP, normal out of office BP), PH (both office and out of office BP abnormal, no underlying cause identified) and SH (both office and out of office BP abnormal, with a secondary cause identified). 548 children and adolescents with mean ± SD age of 10.1 ± 5.8 years and 58.2% girls. Fifty seven percent (n = 314) were hypertensive; of these, 47 (15%), 84 (27%) and 183 (58%) had WCH, PH and SH, respectively. SH presented throughout childhood, whereas PH and WCH peaked in adolescence. Non-White ethnicity was more prevalent within those diagnosed with PH than both the background population and those diagnosed with SH. Higher BMI z-scores were observed in those with PH compared to SH. Hypertensive children <6 years are most likely to have SH and have negligible rates of WCH and PH. PH accounted for 27% of hypertension diagnoses in children and adolescents, with the highest prevalence in adolescence, those of non-White Ethnicity and with excess weight.

White Coat Hypertension Persistence in Children and Adolescents: The Pediatric Nephrology Research Consortium Study

OBJECTIVES

To determine whether youth with white coat hypertension on initial ambulatory blood pressure monitoring (ABPM) continue to demonstrate the same pattern on repeat ABPM.

STUDY DESIGN

Retrospective longitudinal cohort study of patients referred for high blood pressure (BP) and diagnosed with white coat hypertension by ABPM who had follow-up ABPM 0.5-4.6 years later at 11 centers in the Pediatric Nephrology Research Consortium. We classified ABPM phenotype using the American Heart Association guidelines. At baseline, we classified those with hypertensive BP in the clinic as "stable white coat hypertension," and those with normal BP as "intermittent white coat hypertension." We used multivariable generalized linear mixed effect models to estimate the association of baseline characteristics with abnormal ABPM phenotype progression.

RESULTS

Eighty-nine patients met the inclusion criteria (median age, 13.9 years; 78% male). Median interval time between ABPM measurements was 14 months. On follow-up ABPM, 61% progressed to an abnormal ABPM phenotype (23% ambulatory hypertension, 38% ambulatory prehypertension). Individuals age 12-17 years and those with stable white coat hypertension had greater proportions progressing to either prehypertension or ambulatory hypertension. In the multivariable models, baseline wake systolic BP index ≥0.9 was significantly associated with higher odds of progressing to ambulatory hypertension (OR 3.07, 95% CI 1.02-9.23).

CONCLUSIONS

The majority of the patients with white coat hypertension progressed to an abnormal ABPM phenotype. This study supports the 2017 American Academy of Pediatrics Clinical Practice Guideline's recommendation for follow-up of ABPM in patients with white coat hypertension.

Height-based equations as screening tools for high blood pressure in pediatric practice, the GENOBOX study

Due to the absence of easily applicable cut‐off points to determine high blood pressure or hypertension in children, as in the adult population, blood pressure is rarely measured in the pediatrician's clinical routine. This has led to an underdiagnosis of high blood pressure or hypertension in children. For this reason, the present study evaluate the utility of five equations for the screening of high blood pressure in children: blood pressure to height ratio, modified blood pressure to height ratio, new modified blood pressure to height ratio, new simple formula and height‐based equations. The authors evaluated 1599 children between 5 and 18 years. The performance of the five equations was analyzed using the receiver‐operating characteristics curves for identifying blood pressure above P90th according to the American Academy of Pediatrics Clinical Practice Guideline 2017. All equations showed an area under the curve above 0.882. The new modified blood pressure to height ratio revealed a high sensitivity whereas the height‐based equations showed the best performance, with a positive predictive value above 88.2%. Finally, all equations showed higher positive predictive values in children with overweight or obesity. The height‐based equation obtained the highest PPV values above 71.1% in children with normal weight and above 90.2% in children with overweight or obesity. In conclusions, the authors recommend the use of the height‐based equations equation because it showed the best positive predictive values to identify children with elevated blood pressure, independently of their sex, pubertal and weight status.

Prevalence of Secondary Hypertension in Otherwise Healthy Youths with a New Diagnosis of Hypertension: A Meta-Analysis

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.

Obesity and Cardiometabolic Risk Factors: From Childhood to Adulthood

Obesity has become a major epidemic in the 21st century. It increases the risk of dyslipidemia, hypertension, and type 2 diabetes, which are known cardiometabolic risk factors and components of the metabolic syndrome. Although overt cardiovascular (CV) diseases such as stroke or myocardial infarction are the domain of adulthood, it is evident that the CV continuum begins very early in life. Recognition of risk factors and early stages of CV damage, at a time when these processes are still reversible, and the development of prevention strategies are major pillars in reducing CV morbidity and mortality in the general population. In this review, we will discuss the role of well-known but also novel risk factors linking obesity and increased CV risk from prenatal age to adulthood, including the role of perinatal factors, diet, nutrigenomics, and nutri-epigenetics, hyperuricemia, dyslipidemia, hypertension, and cardiorespiratory fitness. The importance of 'tracking' of these risk factors on adult CV health is highlighted and the economic impact of childhood obesity as well as preventive strategies are discussed.

Comparison of Pediatric and Adult Ambulatory Blood Pressure Monitoring Criteria for the Diagnosis of Hypertension and Detection of Left Ventricular Hypertrophy in Adolescents

OBJECTIVE

To compare pediatric ambulatory blood pressure monitoring (ABPM) criteria with adult ABPM criteria for the diagnosis of hypertension and detection of left ventricular hypertrophy (LVH) in adolescents.

STUDY DESIGN

ABPM and echocardiography reports from adolescents age 13-21 years from 2015 to 2019 were analyzed. The concordance of hypertension based on pediatric criteria (American Heart Association 2014) was compared with adult criteria from American College of Cardiology/American Heart Association 2017 (overall BP ≥125/75 mm Hg, wake BP ≥130/80 mm Hg, sleep BP ≥110/65 mm Hg) using the Cohen kappa statistic. Logistic regression, adjusted for body mass index z score, and receiver operating characteristic curves (ROCs) compared pediatric criteria vs adult criteria in predicting LVH (left ventricular mass index >95th percentile reference values and left ventricular mass index >51 g/m^2.7).

RESULTS

Of 306 adolescents, 140 (45.8%) had hypertension based on pediatric criteria vs 228 (74.5%) based on adult criteria; the agreement was poor (59.3%, n = 137, kappa = 0.41). A higher prevalence of LVH was captured by adult criteria only (n = 91) compared with pediatric criteria only (n = 3). Logistic regression found no significant differences between pediatric and adult criteria in the detection of LVH >95th percentile (OR 1.24, CI 0.66, 2.31, P = .51) or >51 g/m^2.7 (OR 1.06, CI 0.47, 2.40, P = .89). ROCs for pediatric criteria were not significant for detecting LVH >95th percentile (0.50, P = .91) or >51 g/m^2.7 (0.55, P = .45), whereas the ROC for adult criteria was significant for detecting LVH >95th percentile (0.59, P = .045) but not >51 g/m^2.7 (0.63, P = .07). Although all individuals with LVH >51 g/m^2.7 were hypertensive by adult criteria, 8 of these individuals were missed by pediatric criteria.

CONCLUSIONS

Adult criteria captured a higher prevalence of LVH and appeared to predict better LVH than pediatric criteria. A consideration to align ABPM criteria for diagnosing hypertension in adolescents with adult guidelines is warranted.

Challenges of diagnosing pediatric hypertension using ambulatory blood pressure monitoring

BACKGROUND

Ambulatory blood pressure monitoring (ABPM) measures mean arterial pressure (MAP) then extrapolates systolic and diastolic blood pressure (BP) values. Pediatric guidelines recommend using calculated systolic and diastolic BP rather than measured MAP for diagnosis of ambulatory hypertension (HTN). The 95th percentile BP that defines ambulatory HTN is higher in some children than thresholds used to define ambulatory HTN in adults.

METHODS

This is a retrospective study of patients who underwent 24-h ABPM. The level of agreement in ambulatory HTN diagnosis using MAP vs. systolic/diastolic BP was evaluated using Cohen's kappa coefficient. Similar analysis was done to assess agreement in HTN diagnosis using adult vs. pediatric criteria for males taller than 165 cm.

RESULTS

A total of 263 ABPM studies were included. There was good agreement for diagnosis of HTN using MAP or systolic/diastolic BP (k = 0.75; 95% CI: 0.67-0.83). However, there was disagreement between the methods in 12% (n = 31) of subjects. Similarly, there was good agreement (k = 0.70; 95% CI: 0.56-0.85) between pediatric and adult criteria for HTN diagnosis. Nineteen patients were found to be hypertensive (9 using MAP criteria, 10 using adult criteria) who would not have met ambulatory HTN criteria using current pediatric guidelines.

CONCLUSIONS

Inclusion of MAP along with systolic and diastolic BP in ABPM analysis alongside using adult criteria for diagnosing HTN in male children ≥ 165 cm may improve accuracy of pediatric HTN diagnosis and reduce false negative rate. Larger studies are needed to assess the clinical validity of these results. Graphical abstract.

Practical application of ABPM in the pediatric nephrology clinic

The use of 24-h ABPM has become commonplace when diagnosing and managing hypertension in the pediatric population. Multiple clinical guidelines recommend ABPM as the preferred method for identifying white-coat hypertension, masked hypertension, and determining degree of blood pressure (BP) control. Accurate, timely diagnosis and optimal management are particularly important in certain populations, such as children with chronic kidney disease (CKD), diabetes, and other conditions with increased risk for cardiovascular disease. Understanding how best to utilize ABPM to achieve these goals is important for pediatric nephrologists and other hypertension specialists. This review will provide practical information on the equipment, application, interpretation, and documentation of ABPM in the specialty clinic.

Pediatric hypertension: Review of the definition, diagnosis, and initial management

Pediatric hypertension (HTN) is a significant and growing health concern. While previously thought to be an uncommon condition in the pediatric population, recent studies have shown an increase in incidence, which is largely due to the obesity epidemic. Accordingly, primary or idiopathic HTN has become more prevalent compared to secondary causes of HTN. The incidence of hypertension is about 3.5%; however, it may be higher as HTN can be missed during routine pediatric well visits. Since childhood HTN frequently tracks into adulthood and is a risk factor for both cardiovascular disease and progression of renal disease; early diagnosis and management of this condition is essential. In this review, we will discuss the approach of a pediatric nephrologist for evaluation and management of pediatric HTN.

Blood pressure in children with chronic kidney disease: lessons learned from the Chronic Kidney Disease in Children Cohort Study

Cardiovascular disease (CVD) is common among children and adolescents with chronic kidney disease (CKD) and end-stage kidney disease (ESRD). However, the early accrual of CVD risk factors in children with CKD has not been well studied. The Chronic Kidney Disease in Children (CKiD) Study, a multicenter, prospective cohort study of children with mild-to-moderate CKD at study entry counts among its primary aims investigation of the drivers of CVD risk in this population. As the most prevalent CVD risk factor in children with CKD, blood pressure (BP) has been a major focus of investigation for the CKiD Study Group. Over the first 15 years of the study, landmark publications have better defined the prevalence of hypertension, the frequency with which it is under-recognized and thus undertreated, and the consequences of elevated BP in this cohort. The purpose of this review is to summarize the contributions made by the CKiD Study in advancing knowledge of BP in this high-risk population, and to highlight areas in need of further study.

Evidence Gaps in the Identification and Treatment of Hypertension in Children

The ultimate goal of recognizing and treating hypertension in childhood is to prevent target-organ damage during childhood and to reduce the risk of adulthood cardiovascular disease. The quality of evidence to guide blood pressure management in children is lower than in adult medicine, yet some common findings support clinical practice recommendations. Oscillometric devices are increasingly replacing manual blood pressure measurements, but evidence shows that readings are not equivalent between the 2 methods. In addition, multiple blood pressure readings are needed before diagnosing a child with hypertension, but the optimal number and timing are still being determined. The recent American Academy of Pediatrics blood pressure guideline has revised the normative data tables and included threshold blood pressure limits which seem to identify children with higher cardiovascular risks. Threshold limits vary between guidelines, and the most accurate threshold has yet to be determined. Lifestyle modifications are a cornerstone of hypertension management, but the optimal diet and physical activity changes for beneficial effect are not known. When pharmacotherapy is needed, physicians have used drugs from all antihypertensive classes in children, yet only a few classes have been systematically studied. The long-term cardiovascular consequences of elevated blood pressure during childhood are under investigation and it seems that the lower the childhood blood pressure the better and that the rate of change during childhood is predictive of adulthood disease. With much still to learn, this article summarizes the evidence and the evidence gaps for the diagnosis, investigation, management, and outcomes of pediatric hypertension.

Pediatric Obesity, Hypertension, Lipids

PURPOSE OF REVIEW

The rise of the pediatric obesity pandemic over the past 40 years has sharpened focus on the management of obesity, hypertension and lipid abnormalities in children. Multiple studies demonstrate that these risk factors track from childhood into adulthood predisposing individuals to premature atherosclerotic cardiovascular disease and putting them at risk for early morbidity and mortality.

RECENT FINDINGS

Importantly, obesity, hypertension and lipid problems are individual risk factors that can occur independently. Multiple studies have shown that each risk factor causes target organ damage in children. Intensive and focused lifestyle modifications can improve a child's subclinical disease and decrease the risk for future morbidity.

SUMMARY

Childhood offers a unique opportunity at primordial and primary prevention of atherosclerotic cardiovascular disease. Clinicians must focus on targeting these highly prevalent conditions and applying lifestyle modification and then pharmacologic or surgical therapies as needed.

Comparative Analysis of American Heart Association and European Society of Hypertension Ambulatory Blood Pressure Thresholds for Diagnosing Hypertension in Children

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.

Predictive Model for Ambulatory Hypertension Based on Office Blood Pressure in Obese Children

Background: The epidemic of obesity, along with hypertension (HT) and cardiovascular disease, is a growing contributor to global disease burden. It is postulated that obese children are predisposed to hypertension and subsequent cardiovascular disease in adulthood. Early detection and management of hypertension in these children can significantly modify the course of the disease. However, there is a paucity of studies for the characterization of blood pressure in obese children through ambulatory blood pressure monitoring (ABPM), especially in the developing world. This study aims to characterize ambulatory blood pressure in obese children and to explore feasibility of using office BP that will predict ambulatory hypertension. Methods:In the present study, 55 children with a body mass index (BMI) in the ≥95th percentile for age and sex were enrolled in a tertiary care hospital and underwent 24 h of ABPM and detailed biochemical investigations. Results:Ambulatory hypertension was recorded in 14/55 (25.5%; white coat hypertension in 17/29 (58.6%) and masked hypertension in 2/26 (7.69%). For office SBP percentile the area under curve (AUC) was 0.773 (95% CI: 0.619-0.926, p = 0.005) and for office DBP percentile the AUC was 0.802 (95% CI: 0.638-0.966, p = 0.002). The estimated cut offs (Youden's index) for office blood pressure which predicts ambulatory hypertension in obese children were the 93rd percentile for systolic BP (sensitivity-67% and specificity-78%) and the 88th percentile for diastolic BP (sensitivity-83% and specificity-62%). Conclusion:Ambulatory blood pressure abnormalities are highly prevalent among children with obesity. Office blood pressure did not accurately predict ambulatory hypertension. More than half of the children labeled as "hypertension" on office blood pressure measurement in the study were diagnosed to have white coat hypertension (WCH), thus emphasizing the role of ABPM for evaluation of WCH before the child is subjected to detailed investigations or started on pharmacotherapy.

Short-term effects of perindopril-amlodipine vs perindopril-indapamide on blood pressure control in sub-Saharan type 2 diabetic individuals newly diagnosed for hypertension: A double-blinded randomized controlled trial

Poor blood pressure (BP) control contributes to complications in sub-Saharan African (SSA) type 2 diabetic individuals. Experts have advocated the use of combination therapies for effective BP control in these patients. The suggested combinations should include a RAAS antagonist and either a CCB or a thiazide diuretic; however, their efficacy is yet to be established in SSA. We investigated the short-term effects of two combination therapies on BP control in SSA type 2 diabetic individuals. This was a double-blinded randomized controlled trial conducted at the Yaoundé Central Hospital (Cameroon) from October 2016 to May 2017. We included type 2 diabetic patients, newly diagnosed for hypertension. After baseline assessment and 24-hour ABPM, participants were allocated to receive either a fixed combination of perindopril + amlodipine or perindopril + indapamide for 42 days. Data analyses followed the intention-to-treat principle. We included fifteen participants (8 being females) in each group. Both combinations provided good circadian BP control after 6 weeks with similar efficacy. Twenty-four-hour SBP dropped from 144 to 145 mm Hg vs 128 to 126 mm Hg with perindopril-amlodipine and perindopril-indapamide, respectively (P = 0.003 for both groups). Twenty-four-hour DBP dropped from 85 to 78 mm Hg (P = 0.013) vs 89 to 79 mm Hg (P = 0.006) in the same respective groups. No significant adverse effect was reported. A fixed initial combination of perindopril-amlodipine or perindopril-indapamide achieved similar effective BP control after 6 weeks in SSA type 2 diabetic individuals with newly diagnosed hypertension. Therefore, these combinations can be used interchangeably in this indication.

White-coat hypertension from a paediatric perspective

AIM

This mini review explored the prevalence of white-coat hypertension (WCH), which is very common in children. It results in elevated office blood pressure (BP) but normal ambulatory BP monitoring (ABPM) readings.

METHODS

WCH can only be identified by analysing and comparing office BP readings and ABPM, which periodically records BP every 20-30 minutes over 24-hour period. This study provides initially the background for WCH in adults, together with a comprehensive overview of the most relevant paediatric data on WCH.

RESULTS

Accurate measurements of BP are very important for the diagnosis and management of hypertension. It is important to acknowledge the clinical relevance of WCH and follow up children who display this BP phenotype by carrying out ABPM, so that clinicians can build up an accurate picture of their BP. It is also important to identify children who have BP issues and are overweight or obese, so that treatment of this modifiable cardiovascular risk factor can be initiated.

CONCLUSION

Using ABPM provides paediatricians with a more precise evaluation of a child's BP readings than office BP readings. It is the gold standard for diagnosing WCH.

Clinical value of ambulatory blood pressure in pediatric patients after renal transplantation

Hypertension is a highly prevalent co-morbidity in pediatric kidney transplant recipients. Undertreated hypertension is associated with cardiovascular complications and negatively impacts renal graft survival. Thus, the accurate measurement of blood pressure is of the utmost importance for the correct diagnosis and subsequent management of post-renal transplant hypertension. Data derived from the general population, and to a lesser extent from the pediatric population, indicates that ambulatory blood pressure monitoring (ABPM) is superior to blood pressure measurements taken in the clinical setting for the evaluation of true mean blood pressure, identification of patients requiring antihypertensive treatment, and in the prediction of cardiovascular outcome. This Educational Review will discuss the clinical value of ABPM in the identification of individual blood pressure phenotypes, i.e., normotension, new-onset hypertension, white-coat hypertension, masked hypertension, controlled blood pressure, and undertreated/uncontrolled hypertension in pediatric kidney transplant recipients. Finally, we examine the utility of performing repeated ABPM for treatment monitoring of post-renal transplant hypertension and on surrogate markers related to relevant clinical cardiovascular outcomes. Taken together, our review highlights the clinical value of the routine use of ABPM as a tool for identifying and monitoring hypertension in pediatric kidney transplant recipients.

Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents

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.

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.

A systems-based approach to managing blood pressure in children following kidney transplantation

Hypertension is one of the most common and well-known complications following kidney transplantation in children. Yet, despite numerous available therapies many pediatric kidney transplant recipients continue to have poorly controlled blood pressure, suggesting that traditional approaches to blood pressure management in this population might be inadequate. Over the last two decades, the Chronic Care Model has been developed to improve chronic illness outcomes through delivery system design and clinical information systems that support patient self-management and provider decision-making. In this educational review we discuss key elements of managing blood pressure following pediatric kidney transplantation and suggest ways that they may be reliably implemented into clinical practice using principles from the Chronic Care Model.

Diagnosis, Epidemiology, and Management of Hypertension in Children

National guidelines for the diagnosis and management of hypertension in children have been available for nearly 40 years. Unfortunately, knowledge and recognition of the problem by clinicians remain poor. Prevalence estimates are highly variable because of differing standards, populations, and blood pressure (BP) measurement techniques. Estimates in the United States range from 0.3% to 4.5%. Risk factors for primary hypertension include overweight and obesity, male sex, older age, high sodium intake, and African American or Latino ancestry. Data relating hypertension in childhood to later cardiovascular events is currently lacking. It is known that BP in childhood is highly predictive of BP in adulthood. Compelling data about target organ damage is available, including the association of hypertension with left ventricular hypertrophy, carotid-intima media thickness, and microalbuminuria. Guidelines from both the United States and Europe include detailed recommendations for diagnosis and management. Diagnostic standards are based on clinic readings, ambulatory BP monitoring is useful in confirming diagnosis of hypertension and identifying white-coat hypertension, masked hypertension, and secondary hypertension, as well as monitoring response to therapy. Research priorities include the need for reliable prevalence estimates based on diverse populations and data about the long-term impact of childhood hypertension on cardiovascular morbidity and mortality. Priorities to improve clinical practice include more education among clinicians about diagnosis and management, clinical decision support to aid in diagnosis, and routine use of ambulatory BP monitoring to aid in diagnosis and to monitor response to treatment.

In-Clinic Blood Pressure Prediction of Normal Ambulatory Blood Pressure Monitoring in Pediatric Hypertension Referrals

OBJECTIVE

Since younger patients have low pretest probability of hypertension and are susceptible to reactive and masked hypertension, ambulatory blood pressure monitoring (ABPM) can be useful. To better target use in referred patients, we sought to define in-clinic systolic blood pressure (SBP) measures that predicted normal ABPM and target end organ damage.

DESIGN, SETTING, PATIENTS, OUTCOME MEASURES

Data were collected on consecutive patients referred for high BP undergoing an ambulatory BP monitor from 2010 to 2013 (n = 248, 33.9% female, mean age 15.5 ± 3.6 years). Candidate in-clinic predictors were systolic maximum, minimum, or average BPs obtained by auscultative, oscillometric, or both. Multivariable logistic regression models were used to determine the prediction of normal ABPM by in-clinic BP predictors. Separate models considered predicting left ventricular hypertrophy (LVH) by in-clinic SBP vs. ABPM-defined hypertension. Identified predictor utility was tested with receiver operator characteristic curves.

RESULTS

Maximum (OR 0.97 [95% CI 0.94-0.99]; P = .047), minimum (0.96 [0.94-0.99]; P = .002), and average (0.97 [0.95-1.00]; P = .04) in-clinic auscultative SBP predicted normal ABPM. Each had a c-statistic of 0.58. LVH was associated with in-clinic auscultative minimum SBP treated continuously (1.05, [1.01-1.10], P = .01) or dichotomized at the 90th percentile (8.23, [1.48-45.80], P = .02), as well as ABPM-defined hypertension (3.31, [1.23-8.91], P = .02). Both predictors had poor sensitivity and specificity.

CONCLUSION

In youth, normal auscultative in-clinic systolic blood pressure indices weakly predicted normal ambulatory blood pressure and target end organ damage.

Pharmacologic Management of Pediatric Hypertension

Hypertension in children is common, and the prevalence of primary hypertension is increasing with the obesity epidemic and changing dietary choices. Careful measurement of blood pressure is important to correctly diagnose hypertension, as many factors can lead to inaccurate blood pressure measurement. Hypertension is diagnosed based on comparison of age-, sex-, and height-based norms with the average systolic and diastolic blood pressures on three separate occasions. In the absence of hypertensive target organ damage (TOD), stage I hypertension is managed first by diet and exercise, with the addition of drug therapy if this fails. First-line treatment of stage I hypertension with TOD and stage II hypertension includes both lifestyle changes and medications. First-line agents include angiotensin-converting enzyme (ACE) inhibitors, thiazide diuretics, and calcium-channel blockers. Hypertensive emergency with end-organ effects requires immediate modest blood pressure reduction to alleviate symptoms. This is usually accomplished with IV medications. Long-term reduction in blood pressure to normal levels is accomplished gradually. Specific medication choice for outpatient hypertension management is determined by the underlying cause of hypertension and the comparative adverse effect profiles, along with practical considerations such as cost and frequency of administration. Antihypertensive medication is initiated at a starting dose and can be gradually increased to effect. If ineffective at the recommended maximum dose, an additional medication with a complementary mechanism of action can be added.

Nocturnal Hypertension and Attenuated Nocturnal Blood Pressure Dipping is Common in Pediatric Lupus

Hypertension is an important manifestation of systemic lupus erythematosus (SLE) but reports of prevalence vary between 20-70% in published reports of adult and pediatric patients. For both children and adults with SLE, the clinical diagnosis and management of hypertension has traditionally been based on guidelines developed for the general population. In clinical trials, the criteria used for defining participants with hypertension are mostly undefined. As a first step towards formally assessing the blood pressure (BP) patterns of children diagnosed with SLE, 24-hr ambulatory BP monitoring data was analyzed on clinic patients who presented with prehypertension or stage I hypertension. In this pediatric SLE cohort (n=10), 20% met daytime criteria for a diagnosis of hypertension. Patterns of BP elevation varied widely with white coat, masked, isolated systolic, and diastolic nocturnal hypertension all identified. Nocturnal hypertension was detected in 60% and attenuated nocturnal BP dipping in 90% of both hypertensive and normotensive SLE patients. In SLE patients, the median nighttime systolic and diastolic loads were 25% and 15.5% compared with median daily loads of 12.5% and 11.5%. Daytime and nighttime systolic and diastolic BP load and nocturnal dipping was compared to a control population consisting of 85 non-SLE patients under 21 years old with prehypertension or stage 1 hypertension presenting to hypertension clinic. Median systolic BP dipped 5.3 mmHg in SLE patients compared to 11.9 mmHg in non-lupus ( p-value = 0.001). Median diastolic BP dipped 12.9 mmHg versus 18.5 mmHg in non-lupus ( p-value = 0.003). Patterns of BP dysregulation in pediatric SLE merit further exploration. Children with or without SLE displaying prehypertensive or stage 1 casual BP measurements had similar rates of hypertension by ambulatory BP monitoring. However, regardless of BP diagnosis, and independent of kidney involvement, there was an increased proportion with attenuated nocturnal dipping and nocturnal hypertension in SLE patients.

Differences between office and ambulatory blood pressures in children and adolescents attending a hospital hypertension clinic

BACKGROUND AND OBJECTIVES

Information on ambulatory blood pressure monitoring (ABPM) in children is scarce. While in adults office BP (OBP) is higher than ABP and the difference increases as OBP increases, information in children suggests that at this young age ABP is no lower and often higher than OBP. This study was aimed at describing OBP-ABP differences in a cohort of children of different ages and BPs, and investigating whether OBP-ABP differences are dependent on age or OBP level.

METHODS

We retrospectively compared OBP and 24-h, daytime and night-time ABP in 433 children and adolescents aged 4-18 years, referred to our hospital clinic.

RESULTS

OBP was found to be significantly lower than 24-h and daytime ABP in the low age tertile (4-10 years) but not in the medium and high tertiles. OBP was also lower than ABP in normotensive patients (n = 182), but higher than ABP in untreated hypertensive patients (n = 92) despite similar ages. Continuous analyses showed a weak correlation of OBP-ABP differences with age, and a much stronger correlation with OBP so that 24-h ABP was higher than OBP at OBP values less than 117/73 mmHg and lower than OBP at higher OBP values. Logistic regression analysis indicates that also in children OBP accounts for most of the OBP-ABP difference.

CONCLUSION

There is a common relation both in children and adults between OBP and ABP. It is only because high OBP is common in the elderly, and the lowest OBP is usually found in young children that large positive OBP-ABP differences have been associated with old age, and negative differences with childhood. OBP-ABP differences, often defined as white-coat effect, can have different directions and are likely to be largely due to regression to the mean.

Using simplified blood pressure tables to avoid underdiagnosing childhood hypertension

BACKGROUND

Recent studies have revealed that hypertension remains underdiagnosed in a significant number of children despite their recorded office blood pressure (OBP) exceeding the recommended fourth report OBP thresholds. Simplified OBP thresholds have been proposed to reduce this underdiagnosis of hypertension in children. In clinical practice, OBP screened as elevated according to the fourth report OBP thresholds are referred for ambulatory blood pressure (ABP) monitoring to rule out 'white coat' hypertension.

OBJECTIVES

The present study tested the usefulness of simplified OBP thresholds to screen abnormal OBP for ABP monitoring referral.

METHODS

A total of 155 subjects were retrospectively analyzed with paired OBP and ABP recordings obtained from an outpatient referral clinic. OBP recordings were classified as abnormal according to the simplified and fourth report OBP thresholds. ABP measurements were classified as abnormal according to the ABP reference tables.

RESULTS

Simplified blood pressure (BP) tables correctly identified all OBP classified as abnormal according to fourth report BP thresholds (kappa [κ] 0.72 [95% CI 0.61 to 0.83]) for systolic OBP; κ 0.92 [95% CI 0.86 to 0.99] for diastolic OBP). OBP classified as abnormal by the simplified BP thresholds and by the fourth report BP thresholds performed similarly for correctly identifying abnormal ABP measurements as per ABP references (overlapping 95% CIs of the sensitivity, specificity and predictive values and likelihood ratios).

CONCLUSIONS

Simplified BP tables, proposed to reduce the underdiagnosis of hypertension in children, can serve as a useful screening tool to decide a referral for ABP monitoring. Future prospective studies are needed to establish these findings.

44-h ambulatory blood pressure monitoring: revealing the true burden of hypertension in pediatric hemodialysis patients

BACKGROUND

The blood pressure (BP) burden is high in pediatric hemodialysis (HD) patients and adversely affects prognosis. The aim of this study was to examine whether 44-h ambulatory BP monitoring (ABPM) provides additional relevant BP data compared with 24-h ABPM.

METHODS

ABPM was initiated at the end of the mid-week dialysis run in 13 stable pediatric HD patients and continued until the next run for 44 h. Day 1 was defined as the initial 24-h ABPM and Day 2 as the time period after that until the next dialysis run. All patients had an echocardiogram to calculate the left ventricular mass index (LVMI).

RESULTS

A higher percentage of patients were diagnosed with hypertension from the 44-h ABPM than from the 24-h ABPM. All BP indexes and loads (except nighttime diastolic load) were significantly higher on Day 2 than on Day 1. Patients with BP loads of ≥ 25 % on 44-h ABPM had significantly higher LVMI than those patients with normal BP loads. No such association was found with 24-h ABPM and LVMI. Higher interdialytic weight gain was associated with higher Day-2 nighttime systolic BP load.

CONCLUSIONS

The 44-h ABPM provides more information than the 24-h ABPM in terms of diagnosing and assessing the true burden of hypertension in pediatric HD patients. Elevated BP loads from 44-h ABPM correlate with a higher LVMI on the echocardiogram.

Ambulatory blood pressure monitoring in clinical practice: a review

Ambulatory blood pressure monitoring offers the ability to collect blood pressure readings several times an hour across a 24-hour period. Ambulatory blood pressure monitoring facilitates the identification of white-coat hypertension, the phenomenon whereby certain individuals who are not taking antihypertensive medication show elevated blood pressure in a clinical setting but show nonelevated blood pressure averages when assessed by ambulatory blood pressure monitoring. In addition, readings can be segmented into time windows of particular interest, for example, mean daytime and nighttime values. During sleep, blood pressure typically decreases, or dips, such that mean sleep blood pressure is lower than mean awake blood pressure. A nondipping pattern and nocturnal hypertension are strongly associated with increased cardiovascular morbidity and mortality. Approximately 70% of individuals have blood pressure dips of ≥10% at night, whereas 30% have nondipping patterns, when blood pressure remains similar to daytime average or occasionally increases above daytime average. The various blood pressure categorizations afforded by ambulatory blood pressure monitoring are valuable for clinical management of high blood pressure because they increase the accuracy for diagnosis and the prediction of cardiovascular risk.

Clinical predictors and impact of ambulatory blood pressure monitoring in pediatric hypertension referrals

Elevated blood pressure (BP) is rising in children. Significant proportions of children have reactive hypertension or masked hypertension, making ambulatory BP monitoring (ABPM) a valuable tool, although with potential economic implications. In youth referred for elevated BP, we sought clinic BP combinations that obviated the need for ABPM and to specify the economic role of ABPM. In a retrospective pediatric referral cohort (N = 170), we examine clinic systolic BP (SBP) predictors of components of ABPM hypertension and their combination. In economic analyses, we compared effectiveness and charges of three diagnostic pathways: (1) clinic BP alone; (2) abnormal clinic BP prompting ABPM; or (3) universal ABPM. ABPM hypertension occurred in 55 (32.4%) and reactive hypertension in 37 (21.8%), average automated (β = 0.208; 95% confidence interval, 0.027, 0.389; P = .03) and maximum auscultatory clinic SBP (β = 0.160; 95% confidence interval 0.022, 0.299; P = .02) were associated with ABPM SBP mean, but none predicted SBP load. No clinic SBP combination was associated with ABPM hypertension. Universal ABPM accrued the lowest average charge per hypertensive youth identified ($10,948). We did not identify a clinic SBP combination that predicted ABPM hypertension in youth referred for elevated BP. Universal ABPM, in this context, may be the most economically and clinically efficient diagnostic strategy.

Rational use of antihypertensive medications in children

Hypertension has traditionally been regarded as an uncommon diagnosis in childhood and adolescence; however, there is compelling evidence to suggest that its prevalence is on the rise, particularly in those with obesity. As a result, pediatricians increasingly are asked to evaluate and manage patients with elevated blood pressure. An increased emphasis on conducting drug trials in children over the last 15 years has yielded important advances with respect to evidence-based data regarding the efficacy and safety of antihypertensive medications in children and adolescents. Unfortunately, data to definitively guide selection of initial agents is lacking. This article will present guidelines for the appropriate use of antihypertensive medications in the pediatric population, including the rational approach to selecting an appropriate medication with respect to pathophysiology, putative benefit, and likelihood for side effects.

Evaluation of hypertension in children

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.

Nighttime blood pressure, systolic blood pressure variability, and left ventricular mass index in children with hypertension

BACKGROUND

Nighttime blood pressure (BP) and systolic BP variability on ambulatory blood pressure monitoring (ABPM) have been strongly associated with target-organ damage in hypertensive adults. The clinical relevance of these variables in children with hypertension remains under-studied.

METHODS

The study group included children aged 5-18 years old referred to the outpatient nephrology clinic for an elevated casual BP who underwent an ABPM and echocardiography (ECHO) study and did not have secondary hypertension. The interpretation of ABPM parameters and left ventricular mass index (LVMI) was based on normative references.

RESULTS

Seventy-two children fulfilled the inclusion criteria. The association of various potential predictors including age, BMI z-score, casual BP z-score and ABPM parameters (BP z-score, BP load, nocturnal dipping and BP variability- within-subject standard deviation (SD) of BP) with LVMI was analyzed. On adjusted regression analysis, nighttime systolic BP load [standardized regression coefficient (β) 0.23; p < 0.05] and daytime systolic BP variability (β 0.37; p < 0.05) had significant association with LVMI.

CONCLUSIONS

In children with primary hypertension, nighttime systolic BP load and daytime systolic BP variability had a stronger association with LVMI than casual BP and other ABPM parameters. Future longitudinal studies are needed to establish the causality among these variables.

Pediatric ambulatory blood pressure monitoring: diagnosis of hypertension

Pediatric hypertension (HTN) is a growing concern and should be diagnosed and treated aggressively to reduce the global disease burden. Ambulatory blood pressure monitoring (ABPM) is a useful clinical tool providing a more accurate description of the patient's blood pressure (BP) than office BP measurements, and can be considered the "gold standard" in the evaluation of the pediatric patient with a concern for HTN. The American Heart Association have suggested criteria for diagnosing ambulatory HTN, and research continues into further clarification of how to best utilize the large volume of data obtained from an ABPM report. ABPM has some limitations; however, the advantages far outweigh these. Routine use of ABPM is recommended among clinicians to better evaluate and assess the severity of a child's HTN, and for proper management in order to prevent target organ damage and the resulting sequelae, thereby reducing the burden of cardiovascular risk in hypertensive children and adolescents.