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

Heart transplantation: comparing the impact of modified heart preservation with conventional methods

The purpose of this study was to compare the impact of modified heart preservation techniques with conventional heart preservation techniques on heart transplant recipients. The goal was to determine if these modified preservation techniques could extend the preservation of the donor heart without increasing the risk of recipient mortality. A retrospective analysis was carried out on 763 cases of orthotopic heart transplantation performed at Wuhan Union Hospital and Nanjing First Hospital, from September 2008 to October 2022. Among these, 656 cases underwent modified heart preservation and were assigned to the study group, while 107 cases underwent conventional heart preservation and were designated as the control group. Detailed information from both groups was collected and compared, including demographic and donor characteristics, survival status, disease type, and recipient/donor characteristics. The study revealed that the modified heart preservation method did not increase the risk of mortality compared to the conventional method. However, it was found that patient factors such as diagnostic classification, recipient age, and donor age significantly influenced mortality risk and were strongly associated with patient survival. The preservation time of the donor heart was significantly longer in the study group compared to the control group, without affecting the survival of the transplant recipients. The findings of our study suggest that modified heart preservation techniques hold promise as a potential method for prolonging heart preservation time. Despite extending the preservation period, these modified techniques did not increase the mortality risk in heart transplant recipients. This could potentially allow for more flexibility in the long-distance transport and preservation of hearts, thereby broadening the scope of viable donors for heart transplantation.

Measurement of Blood Pressure in Children and Adolescents Outside the Office for the Diagnosis of Hypertension

PURPOSE OF REVIEW

To review the benefits of ambulatory blood pressure monitoring and home blood pressure monitoring in children and to discuss implementation of guideline-recommended ambulatory blood pressure monitoring.

RECENT FINDINGS

Compared with office blood pressure, ambulatory blood pressure monitoring and home blood pressure monitoring provide superior accuracy, reproducibility, and stronger associations with target organ damage although future work is needed to determine the utility of home blood pressure monitoring to predict hypertension status on ambulatory blood pressure monitoring. Due to the benefits of out-of-office blood pressure measurement, ambulatory blood pressure monitoring has been recommended to confirm the diagnosis of hypertension in children and adolescents since publication of the 2017 American Academy of Pediatrics clinical practice guidelines on hypertension. However, access to ambulatory blood pressure monitoring remains limited to the subspecialty setting and novel care pathways are needed to improve guideline-concordant use of ambulatory blood pressure monitoring. Nocturnal home blood pressure monitoring may be a practical alternative when ambulatory blood pressure monitoring is not available.

Plasma calcitonin gene-related peptide and nitric oxide predict therapeutic response to amlodipine in pediatric primary hypertension

Background

There is a lack of suitable predictive markers for assessing the efficacy of amlodipine in treating children with primary hypertension. This study aimed to explore whether plasma calcitonin gene-related peptide (CGRP) and nitric oxide (NO) could predict the effectiveness of amlodipine in pediatric primary hypertension.

Methods

This study enrolled 74 children and adolescents with primary hypertension who were prescribed amlodipine monotherapy, and after 4 weeks of treatment, they were divided into responders and non-responders according to blood pressure. Baseline data differences between the two groups were analyzed, followed by binary logistic regression to assess the correlation between significant variables and therapeutic efficacy. The receiver operating characteristic curve was used to evaluate the predictive efficacy, and the nomogram model was established to predict therapeutic response to amlodipine.

Results

The responders exhibited lower body mass index, C-peptide and plasma CGRP levels, and higher NO levels compared to the non-responders (p < 0.05). Multivariable logistic analysis revealed that plasma CGRP and NO were independently associated with the therapeutic response to amlodipine, showing a higher predictive performance when used in combination (AUC: 0.814, 95% CI 0.714-0.914) with a predictive sensitivity of 86.5% and specificity of 70.1%. The nomogram model displayed good calibration, and the decision curve analysis indicated this model led to net benefits in a wide range of threshold probability.

Conclusion

CGRP and NO may be valuable biomarkers for predicting amlodipine effectiveness in the treatment of pediatric primary hypertension, while the nomogram model indicates excellent predictive value.

Development and Validation of Tool for Assessment of Knowledge About Childhood Hypertension Among Final Year Medical Student

Childhood hypertension (HTN) is becoming one of the most important health concerns in children, and it is the most important predictor of adult HTN. The objective was to assess the level of knowledge and to develop and validate questionnaires about childhood HTN among final-year medical students. This facility-based cross-sectional study was conducted from January 2018 to September 2018 in 5 teaching hospitals of Central India. A total of 383 interviews were conducted by non-probability purposive sampling using a validated tool. Exploratory factor analysis was used to assess the validity of the questionnaire, and internal consistency of items was assessed with Cronbach α. A total of 26 items were finalized through consensus. The Kaiser-Meyer-Olkin (KMO) measure of sample adequacy was measures of sampling adequacy (MSA) = 0.83, and Bartlett's test of sphericity was (x2 = 15.89, P = .014). This study shows that the tool developed had acceptable validity and reliability to assess the knowledge about childhood HTN among undergraduate medical students.

Performance of Home-Based and Ambulatory Blood Pressure Monitoring in Obese Children and Their Correlation With End Organ Damage

BACKGROUND

The increasing prevalence of childhood obesity has led to a corresponding increase in hypertension among children, necessitating early identification of subclinical target organ damage for accurate cardiovascular risk assessment. However, in the pediatric population, there is a paucity of literature comparing ambulatory and home blood pressure monitoring, and this knowledge gap is exacerbated by limited access to ambulatory blood pressure monitoring (ABPM) facilities, particularly in developing countries, where pediatricians often resort to home blood BP monitoring as the preferred option.

METHODS

In this cross-sectional study with 60 obese children (aged 5-18 years) at tertiary health care in central India, we aimed to comprehensively characterize blood pressure profiles, including office, ambulatory, and home, and investigated their correlations with indicators of end-organ damage.

RESULTS

Among 60 children, 26 (43.3%) participants were found to be hypertensive based on 24-hour-ABPM evaluation. Masked hypertension (MH) and white coat hypertension (WCH) were observed in 21.6% and 13.3%, respectively. Surprisingly, 20% of participants were identified as hypertensive through 7-day home BP monitoring (HBPM). A notable discordance of 36.6% was between HBPM and ABPM results. Moreover, 26.7% of the children had end-organ damage, with higher odds associated with night-time systolic ambulatory hypertension in the adjusted regression model (OR = 1.06, 95% CI: 1.03-1.10, P < 0.001).

CONCLUSIONS

The study highlights 24-hour ABPM's vital role in classifying hypertensive status, especially in high-risk children. The diagnostic performance of HBPM shows poor sensitivity in detecting MH and lower specificity in identifying WCH compared to ABPM. This limitation translates to missed opportunities for early preventive interventions.

Ambulatory blood pressure monitoring in children and adolescents post-hematopoietic stem cell transplantation

BACKGROUND

One of the long-term complications after hematopoietic stem cell transplantation (HSCT) is hypertension (HT). Previous studies showed that 10-15% of children post-HSCT had office HT, but only a few studies used ambulatory blood pressure monitoring (ABPM). The present study was aimed at exploring the frequency and factors associated with ABPM HT in children post-HSCT.

METHODS

Patients aged ≥ 6 years who survived ≥ 2 years after HSCT were enrolled. Clinical and ABPM data were reviewed. ABPM HT was defined according to the 2022 American Heart Association guidelines. Factors associated with HT were analyzed by logistic regression.

RESULTS

Ninety-eight (60 males) patients with a mean age of 15.1 years and a median follow-up time at 4.5 years after HSCT were included. Fifteen patients (15.3%) had ABPM HT (2 ambulatory HT and 13 masked HT). The ABPM HT group had a significantly older age (19 vs. 14 years), a higher proportion of males (87% vs. 57%), a higher office systolic BP index (0.93 vs. 0.85), a higher office diastolic BP index (0.96 vs. 0.82) and a higher proportion of current use of prednisolone and tacrolimus than those in the normal ABPM group. Multivariate analysis revealed that office diastolic BP index was associated with ABPM HT. Left ventricular mass index was significantly correlated with ABPM but not with office BP parameters.

CONCLUSIONS

HT in children post-HSCT was not uncommon and most could not be detected with office BP measurement. A diastolic BP index can be used as a screening tool for HT. A higher resolution version of the Graphical abstract is available as Supplementary information.

Efficacy of fosinopril and amlodipine in pediatric primary hypertension: a single-center observational study

Objective

Fosinopril and amlodipine are commonly prescribed as first-line pharmacotherapeutic agents for pediatric hypertension, but there is a lack of comparative studies regarding the efficacy of these two drugs. We aimed to evaluate and compare the efficacy of fosinopril and amlodipine monotherapy in pediatric primary hypertension.

Methods

This was a single-center, bidirectional observational study. A total of 175 children and adolescents with primary hypertension receiving antihypertensive monotherapy from July 2020 to February 2023 were enrolled. According to antihypertensive drugs, they were divided into the fosinopril group (n = 96) and the amlodipine group (n = 79). Subgroup analysis was performed to compare the efficacy of the two groups in terms of blood pressure (BP) control rates and reductions following a 4-week treatment.

Results

After 4 weeks of treatment, both groups achieved significant reductions in systolic BP (SBP) and diastolic BP (DBP) by more than 18 mmHg and 6 mmHg, respectively, with BP control rates of 61.5% in the fosinopril group and 59.5% in the amlodipine group, revealing no significant differences in the antihypertensive efficacy between the two groups except for DBP control rate (FDR adjusted P > 0.05). Further subsequent subgroup analyses revealed that the reductions in SBP and DBP in the fosinopril group were significantly greater than those in the amlodipine group in patients of females and hypo-HDL-cholesterolemia (FDR adjusted P < 0.05), and there was a trend of difference, although not significant, in patients with central obesity and insulin resistance (IR) (FDR adjusted 0.05 < P ≤ 0.1). However, there were no significant differences in treatment efficacy in patients without these characteristics. Furthermore, hypertriglyceridemia did not exhibit a significant association with the difference in treatment efficacy between the two medications (FDR adjusted P > 0.05).

Conclusions

Fosinopril and amlodipine monotherapy were both effective in pediatric primary hypertension during a short-term follow-up. Fosinopril may be particularly effective in reducing BP in hypertensive patients of females, central obesity, IR, and hypo-HDL-cholesterolemia. These findings indicate that optimizing antihypertensive medication selection based on the individualized characteristics of children with hypertension may improve the efficacy of antihypertensive treatment.

Hypertension in a cohort of obese Caucasian children and adolescents and its association with glycometabolic indices: A proposed screening tool

BACKGROUND AND AIM

Hypertension (HTN) is common among obese children and adolescents and increases their cardiovascular risk later in adulthood. The aim of the study was to evaluate the prevalence of HTN identified by office blood pressure (BP) measurement and ambulatory BP monitoring (ABPM) in a cohort of obese children and adolescents and its association with anthropometric and glycometabolic indices.

METHODS AND RESULTS

Seventy consecutive obese Caucasian children and adolescents aged 7-16 years were enrolled. Patients underwent ABPM, echocardiogram and carotid ultrasonography. Sex- and age-adjusted logistic multivariable analysis models were used to assess the association between HOMA-IR, HOMA-β, QUICKI with HTN at ABPM. Receiver Operation Curve (ROC) analysis with Youden J statistics was used to identify the optimal HOMA-IR, HOMA-β and QUICKI cut-off to predict HTN at ABPM. Hypertensive office BP was found in 25.7% of obese patients. ABPM diagnosed HTN in 34.9% of patients: 20.6% of obese patients had masked HTN (MHTN), and 12.7% had white coat HTN (WCH). Hypertensive obese patients (according to ABPM) had higher HOMA-IR and HOMA-β, and a lower QUICKI than normotensive subjects. HOMA-IR, HOMA-β and QUICKI predicted HTN at ABPM in obese patients in age- and sex-adjusted logistic multivariable models. Optimal cut-offs to predict HTN at ABPM in obese patients were: HOMA-IR ≥ 3.30, HOMA-β ≥ 226.7 and QUICKI <0.33, with high sensitivity.

CONCLUSIONS

A sequential testing strategy applying office BP and glycometabolic indices can identify hypertensive obese pediatric patients with high diagnostic accuracy and potentially reducing costs. This strategy needs validation in an external and larger cohort.

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.

Machine Learning-Based Prediction of Masked Hypertension Among Children With Chronic Kidney Disease

BACKGROUND

Ambulatory blood pressure monitoring (ABPM) is routinely performed in children with chronic kidney disease to identify masked hypertension, a risk factor for accelerated chronic kidney disease progression. However, ABPM is burdensome, and developing an accurate prediction of masked hypertension may allow using ABPM selectively rather than routinely.

METHODS

To create a prediction model for masked hypertension using clinic blood pressure (BP) and other clinical characteristics, we analyzed 809 ABPM studies with nonhypertensive clinic BP among the participants of the Chronic Kidney Disease in Children study.

RESULTS

Masked hypertension was identified in 170 (21.0%) observations. We created prediction models for masked hypertension via gradient boosting, random forests, and logistic regression using 109 candidate predictors and evaluated its performance using bootstrap validation. The models showed C statistics from 0.660 (95% CI, 0.595-0.707) to 0.732 (95% CI, 0.695-0.786) and Brier scores from 0.148 (95% CI, 0.141-0.154) to 0.167 (95% CI, 0.152-0.183). Using the possible thresholds identified from this model, we stratified the dataset by clinic systolic/diastolic BP percentiles. The prevalence of masked hypertension was the lowest (4.8%) when clinic systolic/diastolic BP were both <20th percentile, and relatively low (9.0%) with clinic systolic BP<20th and diastolic BP<80th percentiles. Above these thresholds, the prevalence was higher with no discernable pattern.

CONCLUSIONS

ABPM could be used selectively in those with low clinic BP, for example, systolic BP<20th and diastolic BP<80th percentiles, although careful assessment is warranted as masked hypertension was not completely absent even in this subgroup. Above these clinic BP levels, routine ABPM remains recommended.

Masked hypertension and correlation between body composition and nighttime blood pressure parameters in children and adolescents with obesity

INTRODUCTION

Masked hypertension is defined as having a normal blood pressure (BP) in the office but elevated BP outside the office. This study aimed to determine the prevalence of masked hypertension in participants with obesity and to examine the correlation between body composition, dietary intake and ambulatory blood pressure parameters.

MATERIALS AND METHODS

The cross-sectional study of participants with obesity was conducted in the pediatric nutrition clinic of a University Hospital in Thailand. Demographic and anthropometric data, dietary intake, body composition analysis and ambulatory blood pressure monitoring were assessed in all participants. All parameters were compared between the group with masked hypertension and the normotensive group. Correlations between the parameters were analyzed.

RESULTS

Among 49 children with obesity, 23 (47%, 95% confidence interval 34.7, 59.2%) had masked hypertension. Compared with the normotensive group, the group with masked hypertension had a greater mean BMI z-score (4.7 vs. 3.0, P = 0.003), a greater mean of body fat percentage (45 vs. 40, P = 0.012) and a greater total energy intake percentage of dietary reference intake (115 vs. 93, P = 0.034). Multivariate analysis showed that BMI z-score was significantly associated with masked hypertension. Interestingly, mean nighttime SBP positively correlated with BMI z-score and body fat percentage. Moreover, there were negative correlations between fruit intake portion per week and nighttime and 24-h SBP index. However, multivariate linear regression did not show significant correlation between these parameters.

CONCLUSIONS

Masked hypertension was frequent in participants with obesity. The greater BMI z-score and percentage of body fat mass correlated with higher nighttime SBP.