7/26/2019 1 Robert C. Holleman, Jr., MD Associate Professor of Clinical Pediatrics Pediatric Nephrology and Hypertension Prisma Health/USC - Midlands PEDIATRIC HYPERTENSION 2019 SCAAP Meeting Disclosures I have no financial or industry relationships to disclose I will not be discussing any off lable medications 1 2
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PEDIATRIC HYPERTENSION - SC Chapter of the American ... · Pediatric Hypertension Can we still blame the kidney? A primary care problem? Objectives/Questions How do we define and
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7/26/2019
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Robert C. Holleman, Jr., MDAssociate Professor of Clinical PediatricsPediatric Nephrology and Hypertension
Prisma Health/USC - Midlands
PEDIATRIC HYPERTENSION
2019 SCAAP Meeting
Disclosures
I have no financial or industry relationships to disclose
I will not be discussing any off lable medications
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Pediatric Hypertension
Can we still blame the kidney?
A primary care problem?
Objectives/Questions
How do we define and stage HTN in children and adolescents?
Who should be screened and how often?
What are the most common causes of pediatric HTN?
What is the appropriate diagnostic plan?
When do we treat with medication and what drugs do we choose?
What is the utility of 24hr ambulatory BP monitoring?
Review the 2017 Clinical Practice Guideline
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Pediatrics. 2017;140(3):e20171904
2017 Clinical Practice Guideline
◆ Update to the 2004 “Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents.”
◆ 17 member subcommittee◆ Endorsed by the American Heart Association◆ 8 significant changes, 30 key action statements
and 27 additional recommendations published in a 72 page document
Flynn JT et al. Pediatrics. 2017;140(3):e20171904
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2017 Clinical Practice Guideline
1) Replacement of the term “prehypertension” with “elevated blood pressure”
2) New normative BP tables (normal weight children)3) Simplified screening table4) Simplified BP classification for adolescents > 13 yrs5) More limited screening recommendation6) Streamlined evaluation and management strategies7) Expanded role for ambulatory BP monitoring8) Revised recommendation on echocardiography
8 Significant changes:
Flynn JT et al. Pediatrics. 2017;140(3):e20171904
Epidemiology
◆ Overall prevalence of pediatric HTN is 3.5%
◆ Prevalence of elevated BP is 2.2-3.5%
◆ Higher in minority populations
◆ ♂ > ♀
◆ BP BMI
◆ Essential HTN is the most prevalent form
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Epidemiology
◆ Overweight and Obese: 4-25%
◆ Sleep Disordered Breathing: 4-14%
◆ Chronic Kidney Disease: 50%
◆ Preterm Birth/Low Birth Weight: 7%
Increased prevalence in select populations:
Flynn JT et al. Pediatrics. 2017;140(3):e20171904
Epidemiology: Risk Factors
Family History
Low birth weight
Obesity Race
Diet – Na intake
Stress
Smoking Physical Activity
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Blood Pressure Measurement
◆ Cuff size critical◆ Comfort/Cooperation◆ At rest for 3-5 minutes◆ Clothing out of the way◆ Right arm, heart level◆ Back supported, feet on floor◆ At least 2 readings
Patient Issues
Blood Pressure Measurement
◆ Cuff size critical
◆ Calibration and upkeep
◆ Auscultatory
- “Gold standard”
- K1 = SBP, K5 = DBP
◆ Oscillometric
◆ Observer bias
Technical Issues
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◆ Bladder width >40% mid arm circumference
◆ Bladder length 80-100% mid arm circumference
◆ Lower edge of cuff ~2cm above olecranon fossa
◆ For severe obesity, use thigh cuff
How do we define Hypertension?
◆ BP level associated with increased morbidity and mortality
◆ Method of measurement- Casual (office) BP
- 24hr ambulatory BP (BP load)
◆ Large pediatric variation by age, size and sex
◆ Task Force data
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Definition of Hypertension
Designation Kids age 1-12 yearsKids age 13 and
older*
Normal BP < 90th %tile < 120/80
Elevated BP90th%tile to < 95th %tile or
120/<80 to < 95th %tile (whichever is lower)
120/<80 to 129/<80
Stage 1 HTN>95th%tile to <95th%tile + 12
or 130/80 to 139/89 (whichever is lower)
130/80 to 139/89
Stage 2 HTN>95th%tile + 12 or > 140/90
(whichever is lower)> 140/90
*Consistent with American Heart Association and American College of Cardiology guidelines
What is “elevated blood pressure?”
◆ Replaces the term “prehypertension” ◆ BP > 90th %tile but < 95th %tile◆ Adolescents with BP 120-129/75-79◆ Implement healthy lifestyle changes and
identify other cardiovascular disease risk factors
◆ Recheck BP in 6 months◆ If BP remains elevated after 12 months ABPM
is recommended◆ At risk for future HTN so follow up is key
Simplified BP TableAge Boys SBP Boys DBP Girls SBP Girls DBP
1 98 52 98 54
2 100 55 101 58
3 101 58 102 60
4 102 60 103 62
5 103 63 104 64
6 105 66 105 67
7 106 68 106 68
8 107 69 107 69
9 107 70 108 70
10 108 72 109 72
11 110 74 111 74
12 113 75 114 75
>13 120 80 120 80
Based on the 90th %tile BP for age at the 5th
%tile for heightDesigned as a screening tool only
Determines which patients need repeat measurements
Provides a negative predictive value of >99%
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BP Screening: why it’s important
◆ HTN is the most common primary diagnosis in the U.S. with healthcare costs in the billions
◆ High BP in adults is an independent risk factor for the development of cardiovascular disease, stroke, and chronic kidney disease
◆ More than 7 million premature deaths worldwide annually in adults attributable to HTN
◆ HTN accounts for 40% of cardiovascular mortality, more than any other risk factor including smoking
BP Screening: why it’s important◆ BP tracking: childhood BP predicts adult BP
✓ Childhood HTN is the strongest predictor of adult HTN
✓ BP at the 90th %tile in childhood increases risk of adult HTN x 2.4
◆ Childhood HTN is associated with increased carotid intima-media thickness, endothelial dysfunction and increased vascular stiffness markers for adult atherosclerosis
◆ The rationale for childhood BP screening as an important strategy for increasing health and decreasing cardiovascular mortality in adults has been endorsed by:
✓ American Academy of Pediatrics ✓ European Society of Hypertension
✓ American Heart Association ✓ National Heart Lung and Blood Institute
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BP Screening: current practice
Type of Visit 2000-2009 2000-2001 2008-2009
All Visits 35% 26% 41%
Preventive Care Visits 67% 51% 71%
Preventive Care Visits + Overweight/Obese
84% 71% 81%
Hypertension Screening During Ambulatory Pediatric Visits in the United States, 2000-2009
- Shapiro DJ et al, Pediatrics, 2012
Data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey
◆ 93,534 ambulatory visits for children age 3 to 18 sampled◆ BP screening more likely in older kids and kids who were overweight/obese◆ Non factors in screening frequency included: race, gender, region, practice
setting and use of an EMR
Who should be screened and how?
◆ All children > 3 years of age annually
◆ Kids with obesity, kidney disease, diabetes, aortic arch obstruction or coarctation, or those on medications known to increase BP should be screened at ALL office visits
◆ Preferred method is auscultation with an age/size appropriate cuff
◆ If initial BP >90th %tile, take 2 additional readings and average them to determine BP stage
Flynn JT et al. Pediatrics. 2017;140(3):e20171904
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Conditions requiring BP screening prior to age 3 years
◆ History of prematurity (<32 wks), SGA, low birth weight, or complicated NICU stay
◆ Congenital heart, renal, or urologic disease
◆ Recurrent UTIs, hematuria, proteinuria
◆ Solid organ/bone marrow transplant or malignancy
◆ Treatment with drugs known to cause BP
◆ Systemic disease associated with HTN
◆ Evidence of increased intracranial pressure
Flynn JT et al. Pediatrics. 2017;140(3):e20171904
Pathophysiology
Hormonal regulation
Genetics Environment
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Etiology of Pediatric HTN
◆ No identifiable cause
◆ Age > 6 years
◆ Positive family history
◆ Closely related to BMI
◆ Negative history
◆ Stress sensitive
◆ Less severe*
◆ Systolic*
◆ Age < 6 years
◆ Lack of co-morbidities or family history
◆ Signs/symptoms more likely
◆ History suggestive
◆ More severe*
◆ Diastolic*
ESSENTIAL HTN SECONDARY HTN
*Not reliable, a loose association
Obesity related HTN
◆ 35-50% of hypertensive adolescents are obese◆ The relationship between BP and weight begins
as early as age 5yrs◆ HTN is three times more common in obese
children◆ Obesity is an independent risk
factor for other cardiovascular morbidity ● insulin resistance/type II DM● dyslipidemia● LVH
◆ Diverse group of drugs: THIAZIDES #1 for chronic HTN; useful as 2nd agent or occasionally as monotherapy; Chlorothiazide, HCTZ LOOP agents acute HTN in certain settings, refractory volume overload; Furosemide, Bumetanide K+ SPARING weak diuretics; use for mineralocorticoid excess or as 2nd diuretic if hypoK; Spironolactone, Amiloride
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Angiotensin Receptor Blockers
◆ Mechanism: Prevents binding of ang II to the type I receptor (vascular smooth muscle and adrenal gland) ➢
vasoconstriction aldosterone◆ Adverse effects: same as ACEI except
cough◆ Contraindications: same as ACEI◆ The “tans”: Losartan, Irbesartan, Valsartan◆ General: less pediatric experience;