Update Pediatric HT Guideline 2017

Update Pediatric HT Guideline 2017

Nanthiya Pravitsitthikul, M.D.

Learning Objectives

• Understand the changes in the new AAP Childhood HT Guideline

• Understand how these changes will affect the management of children and adolescents with high BP

Joseph T. Flynn, Kaelber DC, Baker-Smith CM et al, Clinical practice guideline for screening and management of high BP in childhood and adolescents; Pediatrics 2017;140(3):e20171904

Rationale for the guideline

• Significant increase in interest in childhood HTN since 2004 Fourth Report

• High BP in childhood increase the risk for – Adult HT – CVD

• Even youth with HTN have evidence of accelerated vascular aging – Early heart attacks, strokes, CKD

• Detecting in children may prompt a check of the parents and other family members

Increase prevalence due

to “Obesity”

3.5% of children have

HT

10%-11% have elevated BP


Obesity and risk of HTN in Thai Children

• 30.6% in boys • 12.8% in girls

Obesity (20.9%)

• 4.7% in boys • 3.2% in girls

HTN (3.9%)

• 5.7% for boys • 2.7% for girls Pre HTN

• OR 10.6 • 95%CI 3.75-30

Risk of HTN: Obese

children

•Cross sectional study in two public schools of 693 Thai students

•Age 8-12 yrs, Mean age 10 yrs

•Obesity BMI > P95th

Sukhonthachit P. et al, the association between obesity and blood pressure in Thai public school children, BMC Public Health 2014, 14:729

Obesity and risk of HTN worldwide

Eric L. Cheung et al, Race and obesity in adolescent hypertension. Pediatrics. 2017,139(5): e21061433

Wakako Kawarazaki et al. The role of aldosterone in obesity-

related HT, American Journal of Hypertension 29(4) April 2016

Relative Risk of sustained HTN

Eric L. Cheung et al, Race and obesity in adolescent hypertension. Pediatrics. 2017,139(5): e21061433

Rationale for the guideline

• Prior pediatric HTN guidelines were issue by the National Heart, Lungs, and Blood Institute(NHLBI)

• NHLBI ceased sponsorship of

cardiovascular guideline in 2013

• Increased emphasis on

basing new clinical practice guidelines of thorough literature reviews

NHLBI 1977

NHLBI 1987

NHLBI 1996

NHLBI 2004


Scope of the Guideline

• Subcommittee charged with developing an updated, evidence-based clinical practice guideline – Provide recommendations on

• Diagnosis • Evaluation • Management of Childhood HTN

– Aimed at practicing clinicians seeing patients in the OPD setting


Major Changes from the Fourth Report

1. Rigorous evidence-based methodology 2. Revised definitions of BP categories; alignment with AHA/ACC

Guideline 3. New normative BP tables based on BP from normal-weight

children 4. Simplified screening table

5. Emphasis on use of 24-hr ambulatory BP monitoring (ABPM) to

confirm HTN diagnosis 6. Revised recommendations for performance of echocardiography 7. Lower treatment goals for primary HTN; ABPM goal for CKD


Evidence-based Methodology

• PICOT questions developed by epidemiologist; used for literature search – Cover 2004-2015

• Review of around 15,000 papers by subcommittee members

• Generation of 30 Key Action Statements (KAS) – BRIDGE-Wiz software

• Level of evidence determination based upon AAP grading matrix*

• Patient P • Intervention • Indication I • Comparison C • Outcome O • Time T

*AAP steering committee on Quality Improvement Classifying Recommendation for clinical practice guidelines. Pediatric. 2004;114(3): 874-877

*AAP steering committee on Quality Improvement Classifying Recommendation for clinical practice guidelines. Pediatric. 2004;114(3): 874-877

Definition of HTN (1-18 y/o)

• Lack of outcome data on BP and CV endpoints in children and adolescents

• Childhood HTN in healthy children – the approach since the 1st

NHLBI-sponsored pediatric HTN guideline (1977)

• Subcommittee maintained similar approach due to lack of new evidence

Changes in HTN categorization compared to the fourth report: •BP> P90th Elevated BP

•BP cut-points for stage1&2 HT simplified

•BP cut-points for adolescents > 13 y/o are same as in new AHA/ACC adult HTN guideline


Definition of HTN (1-18 y/o)


Definition of HTN in NB & Infants

• Many factors affect BP in NB, making hard to precisely define HTN

• BP values for NB 26-44 wks post-menstrual age have been complied* and may be used to identify NB with high BP

• 2nd Task Force Report BP curves should still be used for infant 1-12 months of age

*Dionne JM, Abitbol CL, Flynn JT. Hypertension in infancy: diagnosis, management and outcome. Pediatric Nephrol. 2012;27(1): 17-32

Postnatal 7 D

Definition of HTN in NB & Infants

*Dionne JM, Abitbol CL, Flynn JT. Hypertension in infancy: diagnosis, management and outcome. Pediatric Nephrol. 2012;27(1): 17-32

PCA 26-44 wks Birth to 12 mo

New Normative BP Tables

• The 4th Report tables generated from BP values in 70,000 healthy children – Many children had overweight or obesity – Inclusion of these children likely biased normative

BP value upward

• New normative BP tables commissioned for this clinical practice guideline, based only on BP reaching from 50,000 normal-age children






Elevated BP

Stage 1 HT

Stage 2 HT

Simplified BP Table •Full BP tables are complicated

• leads to under-recognition of Childhood HTN

•Simplified BP table created for use in initial screening of BP values

•Based on P90th BP values for children at P5th


Appropriate bladder cuff

Mid-arm circumference Bladder cuff

Width > 40% of MAC Length > 80-100% of MAC Width to length ratio > 1:2

The 4th report on the diagnosis, evaluation and treatment of high BP in children and adolescents; NHBPEP working group. Pediatrics. Vol. 114 No. 2, August 2004

BP Measurement Frequency

• Unclear what age is optimal to begin routine BP measurement

• Data suggest that prevention and intervention efforts should begin early

• New guideline does not change recommendation to begin BP measurement at age 3


Now, only annual measurement is recommended unless risk factors are present

KAS1: BP measurement frequency




KAS2: BP measurement frequency • BP should be checked in all

children and adolescents > 3 y/o at every health care encounter if they have

o Obesity o Taking medication known to

increase BP* o Have renal disease o History of Aortic arch

obstruction or coarctation o Diabetes




Condition under which < 3 year-old should have BP measured

• Neonatal history o Prematurity GA < 32 wks o SGA o VLBW o Neonatal complication need

NICU o Umbilical artery line

• Cardiac o CHF (repaired/unrepaired)

• Transplant o Solid organ transplant o Malignancy/BMT

• Evidence of ICP

• Renal history o Recurrent UTI o Hematuria, Proteinuria o Known renal

disease/structural anomalies o Family history of renal

disease • Medication

o Treatment with known drug induce HT

• Systemic illness asso. HT o NF, TS o Sickle cell disease (SCD)

Repeat high BP measurements

• BP in childhood may vary considerably between visits and even during the same visit

• Many potential etiologies for isolated elevated BP in children and adolescents

• Therefore, the clinician should;

– Repeat high BP reading at a visit – Obtain multiple measurements over time before

diagnosing HTN


KAS3: Diagnosis of HTN



Seat child correctly and measure BP by

Auscultation or by Using oscillometric device

Is Percentile > P90th?

Remeasure BP twice and average these 2

Repeat Ausculatory?

Remeasure BP twice by using auscultatory

technique; average these 2

Classify BP


Patient evaluation and management

• ABPM is done to confirm HTN before initiating diagnostic evaluation

• Treatment may be initiated by primary care provider or subspecialty

If the patient is •symptomatic or

•BP is > 30 mmHg above the P95th •OR > 180/120 mmHg in adolescents

sent to the ED!


KAS5: Oscillometric vs Auscultatory


Ambulatory BP Monitoring


• Should be performed for confirmation of HTN in children and adolescents with office BP measurement in – Elevated BP for > 1 yr OR – Stage 1 HTN over 3 clinic visits

• High risk condition patients (table12) – Reveal masked HTN in high risk group

• Exclude white coat HTN

Ambulatory BP Monitoring


BP patterns by office BP and ABPM

Ambulatory

BP

Office BP

Normal BP Normal Normal

Sustained HTN

Elevated Elevated

White coat HTN

Normal Elevated

Marked HTN Elevated Normal

Courtesy of Professor Joseph T. Flynn; 2017 AAP guideline in childhood hypertension

• Pt wears a BP cuff continually for 24 hrs

oReading q 20-30 min •ABPM allows for evaluation of

oOut-of-office BP oCircadian BP pattern

•New data available regarding Frequency of WCH, masked HTN (MH) Associations with hypertensive target organ damage Application in high-risk populations: CKD, DM, aortic coarctation, solid organ transplantation Cost-effectiveness in pediatric HTN evaluation

ABPM Ambulatory Hypertension


LVH and Echocardiography

• Prevalence of LVH 30-40% in childhood HTN

• LVH increase CV risk independently of BP and BMI

• 2004 Fourth Report

recommended obtaining echo. At time of dx of HTN

• If LVH present, indication to start anti-HTN medications

•Revise definition of abnormal LV mass:

• > 51g/m2.7; or • > 115 g/BSA in boys, • > 95 g/BSA in girls

•LVH is not a treatment target of antihypertensive therapy •Frequent/repeated echocardiography in the presence of LVH or abnormal LV function is encourages


Causes of pediatric Hypertension

11%

65%

11% 10% 3%

Children evaluated at the tertiary pediatric HTN clinic for

elevated BP

Normotension

HT

WCH

PreHT

Dx pending

3(1%) 4(3%)

9(6%) 2(1%)

1(1%)

21(13%)

19(13%)

53(34%)

32(20%)

12(8%)

Causes of secondary HTN in a tertiary pediatric HTN clinic

Autoimmune

Cardiac

Endocrine

GI

Hematology

Medication

Neurology

Renal

Respiratory

Sleep-disorderedbreathing

Essential HT 43%

Secondary HT 57%

Rao G. et al, Diagnosis, epidemiology and management of HT in children. Pediatrics 2016;138(2):e20153616

Monasha Gupta-Malhotra et al, Essential HT vs. secondary HT among children. American Journal of Hypertension 28(1), Jan 2015

KAS19: Overall Treatment Goals


KAS20: Lifestyle Interventions


Pharmacologic treatment

• Prescribe anti-HTN medication if: o Failed at least 6 mo of

lifestyle change o Symptomatic HT

• Stage2HTN without clearly modifiable risk factor (e.g. obesity)

• 1st line agents may include o ACEI/ARB o Long-acting CCB o Thiazide diuretic

• In CKD or DM: o ACEI/ARB


KAS23: CKD


KAS26: DM


Major Points

• Changes in HTN categorization • Revised BP tables and screening table • ABPM to confirm HTN diagnosis and for

special populations • Lower treatment goals and emphasis on BP

reduction, no LVH


Implication for practice

• Review manual BP measurement with your staff and ensure that appropriate equipment is available in your office

• Post new simplified BP table and have more detailed BP table available for consultation

• Develop process for performing/obtaining 24-hr

ABPM • Familiarize yourself with indication for and

approaches to treatment of HTN


THANK YOU FOR YOUR ATTENTION

Update Pediatric HT Guideline 2017

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