PEDIATRIC HYPERTENSION CLINICAL PRACTICE GUIDELINES. Milena Archuleta, MSN, MBA, FNP-BC, CPHON University of New Mexico Hospital

Transcription

1 PEDIATRIC HYPERTENSION CLINICAL PRACTICE GUIDELINES Milena Archuleta, MSN, MBA, FNP-BC, CPHON University of New Mexico Hospital

2 None Disclosures

3 Hypertension: Why so Important? Occurs in 3.5% of all pediatric patients Top 5 chronic diseases in children and adolescents Missed in up to 75% of pediatric primary care visits Higher blood pressure in childhood correlates with higher BP in adulthood More likely to develop metabolic syndrome More likely to have accelerated vascular aging and cerebral vascular accident in adulthood (Flynn et.al., 2017)

4 Prevalence Greater among Hispanic and Non-Hispanic African American Children Higher rates amongst males Higher rates among adolescents vs. younger children More prevalent in adolescents who are overweight or obese Higher rates in children with chronic conditions Obesity, sleep disordered breathing, chronic kidney disease, pre-term birth, endocrine disorders, chronic steroid use (i.e malignancies) (Flynn et. al, 2017)

5 AAP Guidelines American Academy of Pediatrics updated clinical practice guidelines Replaces the 2004 Guidelines Updated tables are based on normal weight children Simplified screening table to identify BPs needing further evaluation Simplified BP classification in adolescents, 13 years of age Consistent with American Heart Association Guidelines and American College of Cardiology adult guidelines Term pre-hypertension has been replaced with elevated blood pressure (Flynn et. al, 2017; Mattoo, 2017)

6 AAP Guidelines Limited recommendation on when to perform BP screening Expanded role for ambulatory BP monitoring Revised recommendations on when to perform echocardiograms (Flynn et. al, 2017; Mattoo, 2017)

7 New BP Tables Based on normal-weight children Do not include children and adolescents with overweight and obesity BMI 85th percentile) Several millimeters of mercury lower than tables in the Fourth Report Include SBP and DBP values arranged by age, sex, and height Categorized as normal (50th percentile), elevated BP (>90th percentile), stage 1 HTN ( 95th percentile), and stage 2 HTN ( 95th percentile + 12 mm Hg) Heights in centimeters and inches (Flynn et.al, 2017)

8 Simplified BP Tables Designed as a screening tool only to identify children and adolescents who need further evaluation of their BP Based on the 90th percentile BP for age and sex for children at the 5th percentile of height Should not be used as single measure to diagnose elevated BP or HTN Actual cut offs should be used for diagnosis For adolescents 13 years of age, a threshold of 120/80 mm Hg is used in the simplified table regardless of sex to align with adult guidelines (Flynn et.al, 2017)

9 Simplified BP Tables

10 Staging of Hypertension in the Adolescent For adolescents 13 years of age Normal Blood Pressure < 120/80 Elevated Blood Pressure 120/80 to 129/<80 Stage 1 Hypertension 130/80 to 139/89 Stage 2 Hypertension 140/90 (Flynn et. al, 2017)

11 Measurement of Blood Pressure Measure beginning at 3 years of age If they are identified as high risk for HTN you can check prior to < 3 yrs old Annual measurement during routine well-child check At every health visit ONLY if adolescent has obesity, taking medications known to increase blood pressure, renal disease, diabetes, h/o of aortic arch obstruction or coarctation of the aorta If BP is elevated, perform 2 additional readings at the same visit and average them Auscultation or Oscillometric device If repeat readings are still elevated, and if using a oscillometric device, repeat auscultation 2 times and average the readings (Flynn et.al, 2017)

12 Primary Hypertension Older age 6 years old Positive family history Parent and/or grandparent Overweight or obese Typically asymptomatic Elevated systolic blood pressure In children 6 years old and a positive family history and overweight or obese, adolescents do NOT require extensive work-up for secondary causes of hypertension (Flynn et.al, 2017; Mattoo, 2017)

13 Secondary Hypertension Younger children, pre-puberty Elevated diastolic blood pressure reading Typically symptomatic with symptoms related to underlying cause Renal disease/ Renovascular disease Coarctation of the aorta Endocrine Disorders Environmental exposures Neurofibromatosis Supplements Medications Steroids, decongestants, cold medications, OCPs, Stimulants, anti-depressants, Erythropoietin, Cyclosporin/Tacrolimus, Asthma medication (Flynn et. al, 2017; Mattoo, 2017)

14 Goals of Evaluation Distinguish between primary and secondary hypertension For children with secondary hypertension, identify and treat underlying cause Identify other comorbid risk factors for coronary vascular disease Obesity, dyslipidemia, diabetes mellitus (Mattoo, 2017)

15 Initial Work-Up Focused History ROS: fatigue, weight loss/weight gain, fevers, flushing, chest pain, palpitations, edema, SOB, snoring, orthopnea Family History HTN, Early CV disease, CVA, End Stage Renal Disease, DM Past Medical History Prematurity, neonatal course, OSA, frequent UTIs

16 Initial Work-Up Social History Tobacco Use, illicit drugs, alcohol, diet, exercise, school/work Feelings of depression, anxiety, bullying and body image perceptions Nutritional History Salt content, sugars, processed foods Medications Steroids, decongestants, cold medications, OCPs, stimulants, anti-depressants, Erythropoietin, Cyclosporin/Tacrolimus, asthma medication, supplements

17 Initial Work-Up Focused Physical Exam Vitals: Repeat BP manually (using appropriate cuff size) Gen: Moon facies, truncal obesity, buffalo hump Skin: Hirsutism, butterfly rash, neurofibromas, café au lait spots HEENT: Retinopathy, crowded oropharynx, enlarged tonsils, thyromegaly CV: Pulses in all 4 extremities, heart sounds (laying, sitting, standing), edema, carotid bruits Resp: crackles, rhonci, wheezing ABD: abdominal mass, pregnancy, abdominal bruits MSK: Pain with ROM, Joint swelling PSYCH: Anxiety

18 Diagnostic Work-Up Initial Diagnostic Work-Up on All Patients: Basic Metabolic Panel Quick assessment of renal function and electrolyte abnormalities Urinalysis Lipid Panel Renal U/S For any adolescent with an abnormal U/A or renal function **Echocardiogram To be done when pharmacologic measures are considered and should be done prior to initiating medications (Flynn, et.al, 2017)

19 Additional Diagnostic Work-Up Overweight/obese (BMI > 95 th percentile): Hemoglobin A1c, Liver Enzymes Concern for OSA: Sleep Study Concern for pregnancy: Urine Pregnancy Test Concern for illicit drug use: UDM (Flynn et.al, 2017)

20 Treatment Goal of treatment is to reduce risk for endorgan damage Reduce risk of coronary vascular disease in adulthood Reduction of BP < 130/80 in adolescents Reduction of BP < 90 th percentile in children

21 Lifestyle Modifications Counsel regarding weight management and nutrition DASH Diet Limit fast food/processed foods, limit sugar, limit sodium Increase servings of fruits and vegetables and low fat dairy Moderate amounts of whole grains, fish, poultry, and nuts Regular daily exercise Goal of 1 hour of physical activity at least 3-5 days per week Encourage participation in a sport Limit screen time and social media to 1-2 hours per day Stress Reduction/Meditation (Flynn et.al, 2017; Mattoo, 2017)

22 Pharmacologic Management Stage I hypertension when there is no response to non-pharmacologic management after 6 months Stage 1 hypertension IF symptomatic and/or with end organ disease Stage II hypertension without a modifiable risk factor Hypertension associated with chronic kidney disease and diabetes Initial treatment recommended by the American Academy of Pediatrics: ACE Inhibitor Angiotensin Receptor Blocker Long-Acting Calcium Channel Blocker Thiazide diuretics (Mattoo, 2017)

23 Pharmacologic Management Avoid beta-blockers and potassium sparing diuretics as initial treatment If not controlled with single agent, may consider adding a second agent of different class Starting doses should be the lowest known dose Medication can be increased every 2-4 weeks until BP is controlled Should be seen in clinic every 4-6 weeks until BP is well controlled Once blood pressure is well controlled, may extend follow-up to every 3-6 months Continue counseling on lifestyle modifications (Flynn et. al, 2017)

24 ACE Inhibitors Mechanism of Action: Prevents conversion of Angiotensin I to Angiotensin II, resulting in increased renin activity and reduction in aldosterone secretion Contraindicated in pregnancy Discontinue immediately if pregnancy is suspected. Can cause injury or death to the fetus Side Effects Common: Cough, headache, dizziness Severe: Hyperkalemia, AKI, angioedema Monitor BUN/Cr and baseline electrolytes prior to starting Periodically check throughout treatment (Up to Date, 2017)

25 ACE Inhibitors Lisinopril Initial Dose: mg/kg/dose once daily Max Initial Dose = 5mg/DAY May increase in 1-2 week intervals Max daily dose= 40mg/DAY Fosinopril < 50 kg: 0.1mg/kg/dose once daily > 50 kg: 5-10mg once daily Max daily dose = 40mg/DAY Other: Benazapril, Captopril, Quinapril Typically very well tolerated When to Consider: Typically used as first line medication; diabetes, Proteinuria, Chronic Kidney Disease (Up to Date, 2017)

26 Angiotensin Receptor Blockers Mechanism of Action: Blocks the vasoconstriction and aldosterone secreting effects of angiotensin II Contraindicated in pregnancy Discontinue immediately if pregnancy is suspected. Can cause injury or death to the fetus Side Effects Common: headache, dizziness Severe: Hyperkalemia, AKI, angioedema Monitor BUN/Cr and baseline electrolytes prior to starting. Periodically check throughout treatment (Up to Date, 2017)

27 Angiotensin Receptor Blockers Losartan 0.7 mg 1.4mg/kg/dose once daily Max Dose = 100 mg/day Valsartan 1.3mg 2.7mg/kg/dose once daily Max Dose = 160mg/DAY Other: Candesartan, Olmesartan, Irbesartan (not indicated in children) Typically well tolerated When to Consider: Could not tolerate ACE due to cough, Diabetes, Proteinuria, Chronic Kidney Disease

28 Calcium Channel Blockers Mechanism of Action: Inhibits Calcium from entering the slow channels of vascular smooth muscle and myocardium during depolarization, producing relaxation of coronary vascular smooth muscle and coronary vasodilation Contraindication: Hypersensitivity to calcium channel blockers; Sick Sinus Syndrome Side Effects Common: flushing, peripheral edema, dizziness Severe: angioedema Monitor heart rate and baseline liver enzymes (Up to Date, 2017)

29 Calcium Channel Blockers Amlodipine Initial dose: 2.5mg-5mg once daily Max Dose= 10mg/DAY Isradapine Initial dose: 0.15 mg- 0.2mg/kg/day divided 3-4 times daily Max dose = 20 mg/day Most adult patients do not show an improvement with doses > 10mg/day Other: Felodipine, Nifedepine When to consider: Diminished renal function, hyperkalemia, and sexually active females who are unable to take or nonadherent to contraception (Up to Date, 2017)

30 Thiazide Diuretics Mechanism of Action: Inhibits sodium reabsorption in the distal tubules causing increased excretion of sodium and water as well as potassium Contraindications: Anuria, hypersensitivity to thiazide diuretics or sulfonamide derived drugs Side Effects Common: Dizziness, hypokalemia Severe: Cardiac dysrhythmia, hyperglycemia, jaundice, pancreatitis Monitor BUN/Cr, glucose, electrolytes. Obtain baseline basic metabolic panel and repeat at least 4 weeks after starting and continue to monitor periodically throughout treatment (Up to Date, 2017)

31 Thiazide Diuretics Hydrochlorothiazide 1mg-2mg/kg/day in 1-2 divided doses Max dose = 100mg/DAY Chlorthalidone 0.3mg/kg/dose once daily Max dose = 50 mg/day When to Consider: Often preferred second agent (Up to Date, 2017)

32 Beta-Blockers Mechanism of Action: Selective inhibitor of beta 1 adrenergic receptors Contraindications: asthma, heart block Side-Effects Common: Bradycardia, dizziness, fatigue, headache, blurred vision Severe: Bronchospasm, dyspnea, heart block Monitor heart rate throughout treatment (Up to Date, 2017)

33 Beta Blockers Metoprolol 0.5mg- 1mg/kg/dose divided BID Max Initial Dose = 25mg/dose Max Daily Dose = 200 mg/day Atenolol 0.5mg- 1mg/kg/dose divided BID or once daily Max Daily Dose = 100 mg/day Other: Propranolol, Carvedilol When to Consider: Adolescents of childbearing potential; children not responsive to ACE, ARB, Thiazides, or Calcium Channel Blockers; Typically 3 rd line agent (Up to Date, 2017)

34 Elevated Blood Pressure Children (1-13): Elevated BP: 90th percentile Adolescents ( 13 years of age): 120/80 to 129/ <80 (Flynn et. al, 2017)

35 Elevated Blood Pressure Lifestyle modifications Weight management Initial labs: Basic Metabolic Panel, Urinalysis, and Lipid Panel Follow-up in 6 months Repeat BP Lifestyle modifications, weight management counseling F/U again in 6 months If BP still elevated after 12 months consider: Ambulatory blood pressure monitoring Full Diagnostic work-up Consider referral to subspecialty If BP normalizes at any point. Return to annual screening

36 Stage 1 Hypertension Children (1-13): 95 th percentile Adolescents ( 13 years of age): 130/80 to 139/89

37 Stage 1 Hypertension Lifestyle modifications Weight management Initial Labs: Initial labs: Basic Metabolic Panel, Urinalysis, and Lipid Panel Repeat BP in 1-2 weeks, if BP still at Stage 1, follow-up in 3 months 3 Month Follow-Up Repeat blood pressure Lifestyle and weight management counseling If still elevated after 3 months consider Ambulatory blood pressure monitoring Diagnostic evaluation Initiate treatment Consider referral to subspecialty (Flynn et. al, 2017)

38 Stage 2 Hypertension Children (1-13): 95th percentile + 12 mm Hg Adolescents ( 13 years of age): 140/90

39 Stage 2 Hypertension Lifestyle modifications and weight management counseling Initial Labs: Basic Metabolic Panel, Urinalysis, Lipid Panel If asymptomatic, repeat BP in 1 week Alternatively may refer to specialty within 1 week If BP remains elevated: Ambulatory BP monitoring Echocardiogram Initiate pharmacologic treatment Refer to subspecialty If symptomatic or BP > 180/120 refer to immediate care (Flynn et.al, 2017)

40 Hypertensive Emergency Symptoms consistent with hypertensive emergency Severe headache, seizures, mental status changes, vomiting, focal neurologic complaints, visual disturbances, chest pain, SOB, palpitations Require immediate pharmacologic management and typically hospitalization for evaluation of ongoing care (Mattoo, 2017)

41 Sports Participation Elevated Blood Pressure (120/80 to 129/<80) May participate in sports without restriction Stage 1 Hypertension (130/80 to 139/89) May participate in sports without restriction if there is no evidence of end organ damage Repeat blood pressure 1-2 weeks after starting sport Stage 2 Hypertension ( 140/90) Restricted from high static sports Once treated and normotensive, may participate in sports without restriction No data linking the presence of HTN to sudden death related to sports participation (Mattoo, 2017)

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43 Lifestyle modifications Dietary Intervention Exercise Prevention

44 AJ 15 year old Hispanic male here for routine sports physical Past Medical Hx: Born at term, vaginal delivery, no complications Broken right wrist after a fall Family Medical Hx: Maternal Grandmother: Controlled Type 2 DM, HTN, Hypothyroid Mother: GERD Father: Controlled Type 2 DM, HTN Sister: Healthy Social History: Exercise: Football games/practice daily for at least 60 min; Weight training 3 days per week Diet: Protein shakes prior to each practice, 2 Dr. Pepper s per day, eats fast food approx 4 d/wk, 3 Bottles of Gatorade per day Tobacco/Drugs/ETOH: Denies use, however does have secondary exposure. Father does smoke Works 20 hours per week at local grocery store Medications: NONE

45 AJ ROS: Tired during the day, headaches after football practice Vital Signs: T: 36.7; HR: 85; RR: 18; O2: 98% RA Wt: 160 lbs (90%); HT: 5 8 (50%); BMI: 24 (90%) BP: 139/88 (automated cuff); 135/80 (1 st manual repeat) ; 138/85 (2 nd manual repeat) Average BP reading: 136/84 Physical Exam Unremarkable Labs: Urinalysis: + for trace protein Review of chart shows BP of 130/80 and 132/82 on 2 separate visits over the last year

46 AJ Diagnosis: Stage 1 Hypertension Proteinuria Overweight

47 AJ Stage 1 Hypertension BMP, urinalysis, lipid panel Lifestyle modifications, weight management counseling Ok to participate in football RTC in 3 months to follow-up BP and lifestyle modifications Proteinuria Renal U/S Overweight Lifestyle modifications, weight management counseling

48 AJ, 3 month Follow-Up Social: Stopped part-time job to focus on sports and school, stopped Dr. Pepper and now only drinking 1 bottle of Gatorade per day, mother packing lunch and cooking dinner daily. Father stopped smoking T: 36.7; HR: 85; RR: 18; O2: 98% RA; Wt:160 lbs (90%); HT: 5 8 (50%); BMI: 24 (90%) BP: 130/80, repeat auscultated measure: 132/85 Physical Exam Unremarkable Labs: BMP-Normal Lipid Panel- Normal Renal U/S: Unremarkable

49 AJ, 3 month Follow-Up Stage 1 Hypertension No response with lifestyle modifications Continue weight management and lifestyle modifications Ambulatory blood pressure monitoring Diagnostic evaluation Considering Treatment: Echocardiogram Consider referral to subspecialty F/U in 1 month to review echocardiogram results

50 AJ, FU Echo Results Echocardiogram is normal Review of Ambulatory BP shows an average reading of 135/80 After a total of 6 months and continued stage 1 hypertension, you decide to initiate medications

51 What Medication to Choose? Lisinopril Metoprolol Losartan Hydrochlorothiazide

52 What Did I Choose? Lisinopril 5mg PO q day

53 What Medication to Choose? Lisinopril Typically well tolerated Low side-effect profile Metoprolol Not generally used as first line medication Would not choose in active teen, due to side-effects particularly fatigue Losartan Also well tolerated Would like to have as a second choice if ACE is not tolerated due to cough Hydrochlorothiazide Often preferred as a second agent Would try to avoid in active teen due to side effects

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55 References Flynn, J., Kaelber, D., Baker-Smith, C., Blowey, D. Carroll, A., Daniels, S., De Ferranti, S., Uribina, E. (2017). Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. American Academy of Pediatrics. Retrieved from Mattoo, T., Stapleton, F., & Kim, M. (2017). Nonemergent Treatment of Hypertension in Children and Adolescents. Up to Date. Retrieved from source=search_result&search=nonemergent%20managment%20hypertension% 20adolescents&selectedTitle=1~150 Mattoo, T., Stapleton, F., & Kim, M. (2017). Evaluation and Management of Hypertension in Children and Adolescents. source=search_result&search=adolescent%20hypertension&selected Title=1~150

56 References Up to Date (2017). Pediatric Drug Information: Amlodipine. Retrieved from source=search_result&search=amlodipine&selectedtitle=2~121 Up to Date (2017). Pediatric Drug Information: Hydrochlorothiazide. Retrieved from source=search_result&search=hydrochlorothiazide&selectedtitle=2~150 Up to Date (2017). Pediatric Drug Information: Lisinopril. Retrieved from source=search_result&search=lisinopril&selectedtitle=2~83 Up to Date (2017). Pediatric Drug Information: Metoprolol. Retrieved from source=search_result&search=metoprolol&selectedtitle=2~150