Hypertension in Childhood: Diagnosis & Management

CONTINUITY CLINIC Measuring BP in Children Children >3 years old Children >3 years old Preferred method: Auscultation with appropriate size cuff Preferred method: Auscultation with appropriate size cuff BP tables include 50 th, 90 th, 95 th, and 99 th percentiles by gender, age, and height BP tables include 50 th, 90 th, 95 th, and 99 th percentiles by gender, age, and height (compiled by NHBPEP Task Forces) Confirm an elevated BP on at least 2 additional visits Confirm an elevated BP on at least 2 additional visits Consider ABPM (portable 24hr BP device) in evaluating “white-coat” HTN, episodic HTN, CRD, DM, autonomic Consider ABPM (portable 24hr BP device) in evaluating “white-coat” HTN, episodic HTN, CRD, DM, autonomic HTN, etc.

CONTINUITY CLINIC Hx of prematurity, very low BW, neonatal complication, NICU Hx of prematurity, very low BW, neonatal complication, NICU Congenital heart disease Congenital heart disease Recurrent URIs, hematuria, or proteinuria Recurrent URIs, hematuria, or proteinuria Known renal disease or urologic malformations Known renal disease or urologic malformations FHx of congenital renal disease FHx of congenital renal disease Solid-organ transplant Solid-organ transplant Malignancy or bone marrow transplant Malignancy or bone marrow transplant Treatment with drugs know to raise BP Treatment with drugs know to raise BP Other systemic illnesses associated with HTN Other systemic illnesses associated with HTN (neurofibramatosis, tuberous sclerosis, etc.) Evidence of elevated intracranial pressure Evidence of elevated intracranial pressure Measuring BP in Children < 3 years

CONTINUITY CLINIC The Right Cuff

CONTINUITY CLINICCLASSIFICATION NORMAL: NORMAL: < 90 th percentilePREHYPERTENSION Average SBP or DBP that are > 90 th to < 95 th percentile if BP >120/80HYPERTENSION Average SBP and/or DBP that is > 95 th for age, gender, and height on 3 separate occasions Stage I HTN Stage I HTN: 95 th -99 th percentile + 5mm Hg Stage II HTN Stage II HTN: > 99 th percentile + 5mm Hg

CONTINUITY CLINIC PRE-ADOLESCENCE ADOLESCENCE PRE-ADOLESCENCE ADOLESCENCE Primary hypertension 15%–30% 85%–95% Primary hypertension 15%–30% 85%–95% Secondary hypertension 70%–85% 5%–15% Secondary hypertension 70%–85% 5%–15% Renal parenchymal disease 60%–70% Renal parenchymal disease 60%–70% Coarctation of the aorta 10%–20% Coarctation of the aorta 10%–20% Renovascular 5%–10% Renovascular 5%–10% Reflux nephropathy 5%–10% Reflux nephropathy 5%–10% Endocrine disorder 3%–5% Endocrine disorder 3%–5% Tumors 1%–5% Tumors 1%–5% Other causes 1%–5% Other causes 1%–5% Causes of HTN in Children

CONTINUITY CLINIC HISTORY OSA

CONTINUITY CLINIC PHYSICAL

LABORATORYEVALUATION SCREENING TESTS UA and culture Electrolytes, Ca 2+, Phos Electrolytes, Ca 2+, Phos BUN/Cr, Uric Acid Lipids CBC with differential

CONTINUITY CLINIC LABS cont’d... SPECIFIC TESTS Fasting insulin & glucose 24-hr urine protein and Cr Urine and serum catecholamines Hormone levels (thyroid, adrenal) ECHORUS

CONTINUITY CLINIC Labs cont’d... SPECIALIZED TESTS Plasma Renin activity and 24-hr urine Na RUS with Doppler of renal arteries Captopril Challenge Renal angiography with renal vein renins MRA Captopril renal scan Ambulatory blood pressure monitoring Renal biopsy

CONTINUITY CLINICMANAGEMENT  Educate  Incorporate patient AND family  Nonpharmacologic measures – T herapeutic L ifestyle C hanges  Antihypertensive Meds  Monitor for side effects and treatment response

CONTINUITY CLINIC OVERVIEW NORMALencourage healthy diet/sleep/exercise PRE-HTNRe-check in 6months TLC STAGE IRe-check 1-2wks - sooner if sx TLC. Initiate pharm tx if indicated STAGE IIEvaluate within 1wk, immediately if patient with sx TLC + pharmacological tx.

CONTINUITY CLINIC T herapeutic L ifestyle C hanges Diet + Exercise =...  Weight loss in obese children results in reduction of both systolic and diastolic BP  Sustained aerobic exercise has a blood-pressure lowering effect in both normotensive and hypertensive persons  Whether excessive Na causes hypertension is still under debate; nonetheless, hypertensive persons benefit from reduction in their Na intake.  Let’s hear it for DASH (Dietary Approaches to Stop Hypertension)!!

CONTINUITY CLINIC To Give or Not To Give...MEDS… When to initiate pharmacological therapy  Symptomatic HTN  Stage II HTN  Stage I HTN refractory to nonpharmacologic therapy.  Target-organ damage (LVH, retinopathy, micoralbuminuria)  Stage I hypertension in patients with diabetes mellitus  CONSIDER if child has additional cardiovascular risks –dyslipidemia, smoking, obesity, family hx, etc.

CONTINUITY CLINIC Choosing an Antihypertensive “Pediatric clinical trials of antihypertensive drugs have focused only on their ability to lower BP and have not compared the effects of these drugs on clinical endpoints.” (NHBPEP Task Force) “Pediatric clinical trials of antihypertensive drugs have focused only on their ability to lower BP and have not compared the effects of these drugs on clinical endpoints.” (NHBPEP Task Force) Physician preference Physician preference Some diuretics and B-Blockers - long hx of safety/efficacy Some diuretics and B-Blockers - long hx of safety/efficacy Newer classes: ACEI, CCB, ARBs studied short term – safe and well tolerated Newer classes: ACEI, CCB, ARBs studied short term – safe and well tolerated Antihypertensives specific to underlying condition or concurrent medical conditions (ACEI in DM, CCB or BB in child with migraines) Antihypertensives specific to underlying condition or concurrent medical conditions (ACEI in DM, CCB or BB in child with migraines)

CONTINUITY CLINIC Principles of Pharmacotherapy #1 Nonpharmacologic measures should be incorporated into every hypertensive child’s treatment plan #2 Drug therapy should be designed to MAXIMIZE compliance and minimize adverse effects #3Stepped Care Approach #4Step Down Therapy