Adolescent Hypertension Roles of obesity and hyperuricemia Daniel Landau, MD Pediatrics, Soroka University Medical Center
Blood Pressure Tables BP standards based on sex, age, and height provide a precise classification of BP according to body size. The revised BP tables now include the 50th, 90th, 95th, and 99th percentiles by sex, age, and height.
http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_measure_child.htm
Blood Pressure Levels for Boys by Age and Height Percentile SBP (mmhg) DBP (mmhg) Age BP Percentile of Height Percentile of Height (Year) Percentile 5th 10th 25th 50th 75th 90th 95th 5th 10th 25th 50th 75th 90th 95th 12 50th 102 103 104 105 107 108 109 61 61 61 62 63 64 64 90th 116 116 117 119 120 121 122 75 75 75 76 77 78 78 95th 119 120 121 123 124 125 126 79 79 79 80 81 82 82 99th 127 127 128 130 131 132 133 86 86 87 88 88 89 90
Tirosh A et al, Hypertension 2010;56:203-9.
Baseline Adolescent BP: (Survival=progression to young adulthood HTN) <100/70 100-109/70-74 110-119/75-79 120-129/80 84 130-139/85-89 Tirosh A et al, Hypertension 2010;56:203-9.
14,187 children & adolescents, seen > 3 times for wellchild care, June 1999 -Sept 2006, northeast Ohio. Proportion of children and adolescents with > 3 elevated BP measurements with a Dx of HTN or pre- HTN documented in the EMR. Of 507 children and adolescents (3.6%) who had hypertension, only 131 (26%) had a Dx of HTN or pre- HTN documented. Patient age, height, obesity-related diagnoses, and magnitude and frequency of abnormal BP readings all increased the odds of diagnosis.
Trends in Antihypertensive Med. Use & BP Control Among US Adults With Hypertension NHANES: Detailed in-person home interviews physical examinations (incl. BP) & labs Have you used prescription drugs in last month? 84% of all reported prescription drugs were obtained from container data. BP measured (X3). If > 140/90 hypertension (n=9421) (2001-10). Increased trend in the use of any antihypertensivein almost all stratified groups Exception: the youngest age group (18-39) & uninsured Gu et al. Circulation 2012; 126: 2105-2114
Gu et al. Circulation 2012; 126: 2105-2114
Prevalence of Persistent Prehypertension in Adolescents Mean of the 2 nd, 3 rd, & 4 th BP measurements BP status/visit, with up to 3 total visits. Acosta et al (Texas). J Pediatr. 2012;160:757-61.
Almost 30% of the students had at least one elevated BP measurement significantly influenced by obesity. Acosta et al (Texas). J Pediatr. 2012;160:757-61.
Bar Dayan et al.
Prevalence of CVD risk factors: US adolescents, 1999-2008. NHANES, n= 3383 (age 12-19 yrs), from 1999-2008. Overall prevalence: prehtn/ HTN: 14% ; Hi LDL: 22%, Low HDL: 6% No change over time predm/dm: 15% increased from 9% to 23% over time Dose-response increase in the prevalence of each of these CVD risk factors by weight categories May et al., Pediatrics. 2012;129:1035-41.
Prevalence of CVD risk factors: US adolescents, 1999-2008. May et al., Pediatrics. 2012;129:1035-41. HTN Hi. LDL Lo. HDL Pre DM/ DM > 2 risk Factors
Sodium Intake & BP Among US Children and Adolescents NHANES 2003 2008 Children & adolescents (8-18 yrs) (n = 6235) Sodium intake estimated (multiple 24-hr dietary recalls) Na intake ~ 3387 mg/day. Overweight/obese: 37% Pre-HTN: 11.5%, HTN: 3.4% Each 1000 mg Na/day increased SD score of SBP among all subjects, and higher SDS increase among overweight/obese subjects All within NL BP range Na intake & weight status synergistic effects on risk for pre-htn/htn Yang et al. PEDIATRICS 130: 611-9;2012
NHANES 2003 2008. Adjusted mean (95% CI) SBP & DBP, US children & adolescents (8-18 yrs), by Na intake quartile and weight status Yang Q et al. Pediatrics 2012;130:611-619 2012 by American Academy of Pediatrics
Childhood Obesity-HTN: Pathophysiology Disturbances in autonomic function Obese children: HR & BP variability Insulin resistance Weight loss in obese adolescents S- insulin & BP previously salt-sensitive individuals insensitive to hypertensive effects of salt-loading Abnormalities in vascular structure and function. In severely obese Vs controls: lower arterial compliance, distensibility & endothelium-dependent and -independent function. Rocchini et al: max. forearm blood flow & min. forearm vascular resistance in obese improved after weight loss (Hypertension. 1992;19:615 20).
Sorof J, J Pediatr 2002
Sorof J et al., J Pediatr 2002;140:660 6. Bogalusa Heart Study : resting heart rate positively correlated with BP & subscapular skinfold thickness (Am J Epidemiol, 1982)
Isolated systolic HTN, obesity, & hyperkinetic hemodynamic states in children Sorof J, J Pediatr 2002
C PS Mild OSA MS OSA Horne et al., Pediatrics. 2011;128:e85-92
Childhood White coat hypertension (WCH): evidence for end-organ effect 119 consecutive children age (mean age = 13.3 yrs; 65% male) referred for High BP with ABPM WCH = 62 & HTN= 57 RESULTS: Office BP did not differ between the 2 groups, but: Awake & asleep DBP + asleep SBP: lower in the WCH group. On treadmill exercise, maximal SBP exceeded norms: HTN: 63% WCH: 38% Lt Ventricular Mass Index > 95th -tile HTN 59%-90% WCH 33-36 % CONCLUSIONS: Exaggerated exercise BP and/or increased LVMI in 62% of those subjects with WCH suggest that this diagnosis in children may represent a prehypertensive state. Kavey RE et al. J Pediatr 2007;150:491-7
BP tracking correlation coefficients for length of follow-up, adjusted for baseline age Chen, X. et al. Tracking of blood pressure from childhood to adulthood: a systematic review and metaregression analysis. Circulation 2008;117:3171-3180
SBP and DBP tracking correlation coefficients against follow-up period Chen, X. et al. Tracking of blood pressure from childhood to adulthood: a systematic review and metaregression analysis. Circulation 2008;117:3171-3180
Tracking of serum lipids, BP & BMI from childhood to adulthood: the CV Risk in Young Finns Study. Study started in 1980 (age 3-18 yrs) 27-yr f/u in 2007 (age: 30-45 yrs) n= 2204 Childhood risk factors were significantly correlated with levels in adulthood. Correl. coefficients: Cholesterol & BMI: 0.43 to 0.56 (P <.0001) BP & TG : 0.21 to 0.32 (P <.0001) The best sensitivity and specificity rates were observed in 12- to 18-year-old subjects. Juhola et al., J Pediatr. 2011;159:584-90
Hypertension, 2005
Allopurinol, 200 mg twice daily, or placebo BID, for 4 weeks
Uric Acid Reduction Rectifies Prehypertension in Obese Adolescents
Sugar Sweetened Beverages, Serum Uric Acid & BP in Adolescents (NHANES) J Pediatr. 2009; 154: 807 813.
Secular trends in BMI & BP among children and adolescents: the Bogalusa Heart Study. 24,092 examinations, n= 11,478 (age: 5-17 yrs), 1974-1993, Bogalusa Heart Study (Louisiana). Obesity prevalence up (6% 17%) during this period. BUT: only small changes were observed in SBP & DBP BMI positively associated with SBP & DBP within each of the 7 examinations controlling for BMI (& other covariates) only ~60% as many children as expected had high BP in 1993. Thus: what has ameliorated the expected increase in BP d/t obesity? Freedman DS et al., Pediatrics. 2012;130:e159-66.
BP Z scores, South Korea, boys & girls, age 10-19 yrs, 1998 Vs 2007/8. (Korean NHANES) Khang Y, and Lynch J W Circulation 2011;124:397-405
Childhood Ideal cardiovascular health (AHA) Simultaneous presence of 4 ideal health behaviors never tried or never smoked a whole cigarette BMI <85th percentile physical activity at goal levels diet consistent with current guideline recommendations AND : 3 ideal health factors Untreated total Chol. <170 mg/dl Untreated BP <90th percentile Untreated fasting plasma glucose <100 mg/dl Index: 0 (worst) 7 (best)
Ideal CV Health in childhood and cardiometabolic outcomes in adulthood: the Cardiovascular Risk in Young Finns Study. Cardiovascular health: the presence of both ideal health behaviors and ideal health factors. N=856, (age: 12-18 yrs) followed up for 21 yrs (1986 2007) Health factors and behaviors in childhood cardiometabolic outcomes in adulthood Ideal CV health metrics in childhood reduced adulthood risk of: HTN (OR 0.66 [0.52-0.85], P<0.001) Metabolic syndr (0.66 [0.52-0.77], P<0.001) Hi. LDL (0.66 [0.52-0.85], P=0.001) High-risk carotid a. IMT (0.75 [0.60-0.94], P=0.01). Leitinen TT et al., Circulation. 2012;125:1971-8.
Unadjusted (A) & age+sex-adjusted (B) adult carotid IMT in different ideal child cardiovascular health index groups. Copyright American Heart Association Laitinen T T et al. Circulation 2012;125:1971-1978
Prevention Relatively advanced levels of atherosclerosis (fibrous plaques) can be present in adolescents and young adults. Risk factors for plaque extent (PM) & carotid IMT (Bogalusa Heart Study, Finland): Hi. BMI, HTN, Hi. LDL-Chol, Lo. HDL-C, DM, cigarette smoking (Berenson GS, et al. NEJM 1998;338:1650 6) (Juonala M, et al. Circulation. 2010;122:2514). Low-CVD-risk status maintained to age 50 yrs very low future risk of CVD. (Lloyd-Jones DM, et al. Circulation 2006;113:791 8).
Childhood Adiposity, Adult Adiposity, and Cardiovascular Risk Factors Data analysis, 4 prospective cohort studies (Finland, Australia, USA ) (n=6328), childhood & adult BMI. Follow-up: ~ 23 yrs. Child obese >>> Adult obese --> Hi. Risk for HTN, dyslipidemia, T2DM, carotid IMT. Child obese >>> adult non obese --> regular risk. Juonala M et al. N Engl J Med 2011;365:1876-85
CO-ANO CNO-ANO CO-AO CNO-AO
Exercise and BP Exercise has been shown to help reduce both SBP & DBP in those with HTN Temporary restriction: only for those athletes who have stage 2 HTN until normal BP is achieved. Dynamic exercise (exerting muscles through joint movement) --> SBP & MAP up, but: DBP & total peripheral resistance- down. In static exercise (exerting muscles without joint movement) --> relatively large intramuscular forces develop without much change in muscle length or joint motion. SBP. MAP & DBP increase significantly, and total peripheral resistance remains essentially unchanged PEDIATRICS Volume 125, Number 6, June 2010
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