Pediatric Hypertension. Alisa A. Acosta, MD, MPH Asst. Professor, Renal Section April 5, 2019

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1 Pediatric Hypertension Alisa A. Acosta, MD, MPH Asst. Professor, Renal Section April 5, 2019

2 Objectives Recognize the importance of accurate blood pressure measurement in pediatric patients Define pediatric hypertension (HTN) according to the 2017 AAP Clinical Practice Guidelines Evaluate a pediatric patient with HTN Manage basic pediatric HTN Page 1 xxx00.#####.ppt 4/3/19 10:21:07 AM

3 Page 2 xxx00.#####.ppt 4/3/19 10:21:08 AM

4 Adult Data Absolute Risk for Ischemic Heart Disease Mortality Systolic BP (Graph looks similar for stroke risk) Lancet 2002; 360: Page 3 xxx00.#####.ppt 4/3/19 10:21:09 AM

5 HTN in Adults Almost one in three adults has HTN (32.6%) - Almost half don t know it (17.2%) - Almost 46% are under-treated Mozaffarian D et al, Circulation 2016;133: Lowering BP in adults with Stage 1 HTN leads to a reduction in the incidence of: - Myocardial infarctions (20-25%) - Stroke (35-40%) - Heart Failure (>50%) - AND overall mortality (~10% at 10 years) Chobanian, Hypertension 2003;42: Page 4 xxx00.#####.ppt 4/3/19 10:21:09 AM

6 Pediatric Hypertension Generally healthy children with primary HTN do not suffer from CV end points seen in adults Children with elevated BP are likely to become adults with hypertension Prevention, early detection, and appropriate treatment for those at risk is the way to eliminate the burden of this disease Page 5 xxx00.#####.ppt 4/3/19 10:21:10 AM

7 History of Hypertension in Pediatrics Before 1977: no accepted normative data 1977: 1 st Task Force Report (3 sources) - Normative data for children - Defined HTN >95 th percentile for age & gender 1987: 2 nd Task Force Report (9 sources) - Additional data for over 60,000 children - Improved racial mix 1996: Task Force Update - Incorporated height in the BP norms 2004: Fourth Working Group Report 2017: AAP Clinical Practice Guidelines (CPG) Page 6 xxx00.#####.ppt 4/3/19 10:21:11 AM

8 Page 7 xxx00.#####.ppt 4/3/19 10:21:11 AM

9 Table 1 Summary of KAS for Screening and Management of High BP in Children and Adolescents Page 8 xxx00.#####.ppt 4/3/19 10:21:12 AM

10 Table 11 Patient Evaluation & Management According to BP Level Page 9 xxx00.#####.ppt 4/3/19 10:21:13 AM

11 Classification of BP Children Page 10 xxx00.#####.ppt 4/3/19 10:21:14 AM

12 Epidemiologic Definition z = % 5% Page 11 xxx00.#####.ppt 4/3/19 10:21:15 AM

13 Who should have BP measured Children 3 years old should have BP measured annually Children 3 yrs at every health care encounter if meds/conditions increase risk for HTN Children < 3 years should have BP measured under special circumstances Page 12 xxx00.#####.ppt 4/3/19 10:21:16 AM

14 Special Circumstances for Children < 3 years old - Prematurity <32 wks or SGA, VLBW, other - Congenital heart disease - Renal disease or urologic malformation Recurrent UTI, hematuria, proteinuria FH of congenital renal disease - Solid-organ transplant - Malignancy or BMT - Tx with meds known to raise BP - Other systemic illnesses a/w HTN (NF, TS) - Evidence of elevated intracranial pressure Page 13 xxx00.#####.ppt 4/3/19 10:21:17 AM

15 Page 14 xxx00.#####.ppt 4/3/19 10:21:17 AM

16 Four Clinical Questions 1. Does my patient have hypertension? 2. Why does my patient have hypertension? 3. Is there any evidence of target organ damage? 4. Are there any other modifiable risk factors for CVD? Page 15 xxx00.#####.ppt 4/3/19 10:21:18 AM

17 Case 1 A 7 year old boy comes to your office for a well child check. Ht is 25 th % and wt is >95 th %. In triage using a machine and a child cuff, his blood pressure measures 117/78. His history and exam are normal. Does he have an elevated blood pressure? Page 16 xxx00.#####.ppt 4/3/19 10:21:19 AM

18 50 th %ile - 94/56 90 th %ile - 107/68 95 th %ile - 110/71 95 th /83 Pt s BP: 117/78 Page 17 xxx00.#####.ppt 4/3/19 10:21:19 AM

19 Dilemma of BP Measurement Norms based on auscultatory measurements with mercury manometers Oscillometric monitors are largely used - Poor correlation with auscultatory methods - Measure the MAP, calculates SBP & DBP using proprietary, unpublished algorithms BP > 90 th percentile by oscillometric devices should be repeated by auscultation Page 18 xxx00.#####.ppt 4/3/19 10:21:21 AM

20 BP Measurement Properly positioned -Seated -Back Supported -Feet on the floor -Arm resting at heart level After 5 mins of rest Empty bladder Avoidance of stimulant drugs or foods 30 mins prior Page 19 xxx00.#####.ppt 4/3/19 10:21:21 AM

21 Proper Cuff Size Small cuffs overestimate BP more than large cuffs under-estimate BP Between sizes, choose the larger cuff Page 20 xxx00.#####.ppt 4/3/19 10:21:22 AM

22 Case 1 You re-measure the blood pressure by auscultation after at least 5 minutes of rest. You measure the arm circumference to be 32 cm. Child cuff cm Adult cuff cm Page 21 xxx00.#####.ppt 4/3/19 10:21:23 AM

23 After changing to an adult cuff, his blood pressure was recorded as 105/67 50 th %ile - 94/56 90 th %ile - 107/68 95 th %ile - 110/71 95 th /83 Pt s Original BP: 117/78 Page 22 xxx00.#####.ppt 4/3/19 10:21:23 AM

24 Does this patient have hypertension? no Page 23 xxx00.#####.ppt 4/3/19 10:21:25 AM

25 Case 2 A 14 yr old boy has multiple visits with an elevated blood pressure ranging from the 130s- 143/ 70s-90 measured by auscultation with an appropriate sized cuff Height and weight =95 th percentile Remainder of his history and physical exam is benign, and there is no family history of hypertension Page 24 xxx00.#####.ppt 4/3/19 10:21:25 AM

26 Does this patient have hypertension? Patient s BP = 130s-143/ 70s-90s Page 25 xxx00.#####.ppt 4/3/19 10:21:26 AM

27 Is clinic BP the best measure? 24 hr Ambulatory Blood Pressure Monitoring Useful in the evaluation of - White coat hypertension - Apparent drug resistant hypertension - Evaluation of drug-induced hypotension Provides an overall BP pattern - BP load - Nocturnal BP Page 26 xxx00.#####.ppt 4/3/19 10:21:27 AM

28 24 hr Ambulatory BP Monitoring White-Coat Hypertension - Clinic BP is high but ambulatory BP (ABP) is normal - Prevalence in children is up to 62%, probably 20% - Pre-hypertensive state? Masked Hypertension - Clinic BP is normal but the ABP is elevated - Occurs in ~10% of youth - Same risk for CVD as those with sustained HTN Page 27 xxx00.#####.ppt 4/3/19 10:21:27 AM

29 Case 2: 24 hr ABPM Systolic BP Mean Arterial Pressure Diastolic BP Page 28 xxx00.#####.ppt 4/3/19 10:21:28 AM

30 130 mmhg 77 mmhg 95 th %ile Page 29 xxx00.#####.ppt 4/3/19 10:21:29 AM

31 Does this patient have hypertension? technically, no white coat HTN Page 30 xxx00.#####.ppt 4/3/19 10:21:29 AM

32 Case 3 An 8 yr old boy had an elevated mean BP by auscultation with an appropriate sized cuff on 3 separate occasions: 148/78, 154/90, 142/81 Asymptomatic, no significant PMH. MGM has HTN Wt 34.5kg (75%), Ht 131.5cm (25%), BMI 20.6 (90%) BP in RLE 103/72 Exam is benign but difficult to palpate LE pulses Page 31 xxx00.#####.ppt 4/3/19 10:21:30 AM

33 Case 3 Does this patient have hypertension? 148/78, 154/90, 142/81 Yes, Stage II 90 th %ile 110/72 95 th %ile 114/77 99 th %ile 122/85 Why does he have hypertension? Page 32 xxx00.#####.ppt 4/3/19 10:21:31 AM

34 Evaluation for Secondary HTN Secondary hypertension is more common in children The younger the child and /or the more severe the hypertension, the more likely there is a secondary cause Page 33 xxx00.#####.ppt 4/3/19 10:21:31 AM

35 Causes of Hypertension Renal parenchymal disease - Congenital anomalies of the urinary tract - Glomerulonephritis - Polycystic kidney disease - Sequelae of acute kidney injury, i.e. HUS - Chronic kidney disease - Systemic vasculitis with renal involvement Renovascular defect - Fibromuscular dysplasia - Midaortic syndrome - Renal vein thrombosis Page 34 xxx00.#####.ppt 4/3/19 10:21:32 AM

36 Causes of Hypertension Coarctation of the aorta Pulmonary - Chronic lung disease of the newborn Monogenic forms - AME - Liddle s syndrome - Gordon s syndrome - GRA Renal Tumors Endocrine - Catecholamine excess Pheochromocytoma Paraganglioma Neuroblastoma - Cushing syndrome - Hyperaldosteronism - Thyroid disorders - Congenital adrenal hyperplasia - Hypercalcemia Page 35 xxx00.#####.ppt 4/3/19 10:21:32 AM

37 Initial Evaluation Page 36 xxx00.#####.ppt 4/3/19 10:21:33 AM

38 Initial Evaluation Thorough history and physical exam Electrolytes, BUN, creatinine CBC +/- Thyroid function studies Urinalysis +/- urine cx Renal ultrasound - Scars - Congenital anomaly - Discordant kidney size Page 37 xxx00.#####.ppt 4/3/19 10:21:34 AM

39 Further Evaluation Renovascular imaging Plasma renin Plasma and urine steroid levels Plasma and urine catecholamines Page 38 xxx00.#####.ppt 4/3/19 10:21:35 AM

40 Case 3 Normal renal ultrasound Normal urinalysis Normal electrolytes, BUN, Cr Normal thyroid function tests Echocardiogram - Functional bicuspid aortic valve - Distal aortic arch appeared narrowed - Abdominal Doppler suggested mild obstruction - Mild concentric left ventricular hypertrophy Page 39 xxx00.#####.ppt 4/3/19 10:21:36 AM

41 Four Clinical Questions 1. Does my patient have hypertension? Yes 2. Why does my patient have hypertension? Coarctation of the aorta Page 40 xxx00.#####.ppt 4/3/19 10:21:37 AM

42 Case 4 11 yr old female, elevated BP by auscultation on multiple occasions, /78-89, confirmed by ABPM She is asymptomatic. Mom and maternal grandparents have hypertension. Negative PMH Wt 91.4kg (>97%), Ht 160.9cm (>97%), BMI 35.3kg/m 2 (>95%) Exam is unremarkable including 4 extremity BP Page 41 xxx00.#####.ppt 4/3/19 10:21:37 AM

43 Four Clinical Questions 1. Does my patient have hypertension? / th %ile 120/77 Yes, stage I 95 th %ile 124/81 99 th %ile 131/89 2. Why does she have hypertension? Page 42 xxx00.#####.ppt 4/3/19 10:21:38 AM

44 Case 4 Normal urinalysis Normal electrolytes, BUN, Cr Normal thyroid function tests Normal renal ultrasound (not indicated) Page 43 xxx00.#####.ppt 4/3/19 10:21:38 AM

45 Four Clinical Questions 1. Does my patient have hypertension? Yes 2. Why does my patient have hypertension? Primary hypertension, likely obesity-related, family history, etc. Page 44 xxx00.#####.ppt 4/3/19 10:21:39 AM

46 The Obesity Epidemic Page 45 xxx00.#####.ppt 4/3/19 10:21:40 AM

47 Prevalence of Obesity* Among US Children and Adolescents (aged 2 19 years) 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% NHANES II NHANES III NHANES NHANES *age and sex-specific BMI 95 th percentile Ages 2-5 Ages 6-11 Ages Page 46 xxx00.#####.ppt 4/3/19 10:21:41 AM

48 Hypertension follows Obesity Distribution of BMI percentiles and the prevalence of HTN within each BMI percentile category Sorof et al, J Pediatr 2002;140:660-6 Page 47 xxx00.#####.ppt 4/3/19 10:21:41 AM

49 Four Clinical Questions 1. Does my patient have hypertension? Yes 2. Why does my patient have hypertension? Likely obesity-related, family history 3. Is there any evidence of target organ damage? Page 48 xxx00.#####.ppt 4/3/19 10:21:43 AM

50 Target Organ Damage Measurable abnormalities attributed to HTN that occur before significant cardiovascular events -Microalbuminuria or overt proteinuria -Hypertensive retinopathy -Left ventricular hypertrophy -Increased carotid artery intima media thickness -Decreased vascular compliance Page 49 xxx00.#####.ppt 4/3/19 10:21:43 AM

51 Left Ventricular Hypertrophy Most prominent evidence of target organ damage - Echocardiography should be performed at the time of consideration of pharmacologic therapy - Monitored every 6-12 months Page 50 xxx00.#####.ppt 4/3/19 10:21:44 AM

52 Four Clinical Questions 1. Does my patient have hypertension? Yes 2. Why does my patient have hypertension? Likely obesity-related, family history 3. Is there any evidence of target organ damage? Yes, LVH on echocardiogram 4. Are there any other modifiable risk factors for CVD? Page 51 xxx00.#####.ppt 4/3/19 10:21:45 AM

53 Evaluation for Co-morbidities Fasting labs -Lipid panel -Hgb A1c -AST, ALT If indicated: -Drug Screen -TSH -CBC -Polysomnography Snoring or other symptoms of sleep disorded breathing Nocturnal hypertension Page 52 xxx00.#####.ppt 4/3/19 10:21:45 AM

54 Case 4 Fasting labs - Normal lipid panel - Normal Hgb A1c Sleep Study - Obstructive sleep apnea - Treated with CPAP Page 53 xxx00.#####.ppt 4/3/19 10:21:46 AM

55 Four Clinical Questions 1. Does my patient have hypertension? Yes 2. Why does my patient have hypertension? Likely obesity-related, family history 3. Is there any evidence of target organ damage? Yes, LVH on echocardiogram 4. Are there any other modifiable risk factors for CVD? Several: wt management, insulin resistance, sleep apnea Page 54 xxx00.#####.ppt 4/3/19 10:21:47 AM

56 Now what? How should I treat my patient s hypertension?

57 Meds or no meds? Therapeutic lifestyle changes initiated in all patients - Healthy eating - Regular cardiovascular exercise - Good sleeping habits Family-based intervention improves success Avoid stimulant medications when possible Page 56 xxx00.#####.ppt 4/3/19 10:21:48 AM

58 Weight Loss Indicated in obesity-related HTN Weight loss improves - BP in overweight adolescents - Salt sensitivity of BP - Decreases other cardiovascular risk factors Dyslipidemia Insulin resistance Page 57 xxx00.#####.ppt 4/3/19 10:21:49 AM

59 Page 58 xxx00.#####.ppt 4/3/19 10:21:49 AM

60 Sodium Restriction Increased sodium intake is associated with higher BP at all ages Current Recommendations year olds 1.2 g/day - > 8 years 1.5 g/day Page 59 xxx00.#####.ppt 4/3/19 10:21:50 AM

61 Page 60 xxx00.#####.ppt 4/3/19 10:21:51 AM

62 Physical Activity Regular physical activity is beneficial for preventing and treating HTN in adults In children - Inverse relationship between fitness and SBP - Improved fitness slows the progression of elevated BP at one year - Studies suggest an effect of exercise on BP reduction independent of weight loss Page 61 xxx00.#####.ppt 4/3/19 10:21:51 AM

63 Indications for Pharmacotherapy Symptomatic hypertension Secondary hypertension Stage 2 hypertension Target organ damage Diabetes (types 1 and 2), CKD Persistent hypertension despite nonpharmacologic measures Page 62 xxx00.#####.ppt 4/3/19 10:21:52 AM

64 Pharmacotherapy Clinical trials have expanded the number of drugs with pediatric dosing Pharmacotherapy should be initiated with a single drug Goal is a reduction of BP to <95th percentile - Goal of <90th percentile if concurrent conditions are present Page 63 xxx00.#####.ppt 4/3/19 10:21:53 AM

65 Pharmacotherapy ACE inhibitor Angiotensin-receptor blocker Benazepril, Captopril, Enalapril, Fosinopril, Lisinopril, Quinapril Irbesartan, Losartan, Valsaratan, Telmisartan α- and β-antagonist Labetalol β-antagonist Calcium channel blocker Central α- agonist Diuretic Peripheral α- antagonist Vasodilator Atenolol, Bisoprolol/HCTZ, Metoprolol, Propranolol Amlodipine, Felodipine, Isradipine Extended-release nifedipine Clonidine Furosemide, HCTZ, Amiloride Spironolactone, Triamterene Chlorthalidone Doxazosin, Prazosin, Terazosin Hydralazine, Minoxidil

66 Choosing a Medication Based on benefit/side effect profile, availability, and ease of administration No evidence HCTZ should be first line agent Racial differences in response to various drug classes have yet to be shown Maximize the dose of single agent before adding additional agents Page 65 xxx00.#####.ppt 4/3/19 10:21:53 AM

67 Choosing a Medication Calcium channel blockers are generally safe first line agents while awaiting evaluation Beta blockers - Avoid the use in asthma patients - Preferred drug if history of migraine HA Avoid ACEi and ARB until renal evaluation is complete Page 66 xxx00.#####.ppt 4/3/19 10:21:54 AM

68 Page 67 xxx00.#####.ppt 4/3/19 10:21:55 AM

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