Pediatric Hypertension and Hyperlipidemia: Screening and Referral Jeffrey Harris, MD Pediatric Cardiology Marshall Pediatrics Hoops Family Children’s Hospital 6/17/2015

Objectives 1. Learn screening guidelines for dyslipidemia in children and adolescents 2. Learn screening guidelines for hypertension in children and adolescents 3. Understand appropriate technique/cuff size for measuring BP 4. Understand basic workup for pediatric HTN, including labwork and imaging. 5. Understand indications for referral to a lipid or hypertension specialist.

Cardiovascular Disease Atherosclerosis begins in childhood Risk factors can be identified in childhood Clinical events include: MI, stroke, PDA, and ruptured aortic aneurysm Risk factors track from childhood into adult life Interventions exist for management of identified risk factors

Cardiovascular Disease

Hypertension Definitions Hypertension is defined as average SBP and/or DBP ≥95th percentile for gender, age, and height on ≥3 occasions Prehypertension: average SBP or DBP levels ≥90th but <95th percentile Adolescents: BP levels ≥120/80 mmHg should be considered prehypertensive. White coat hypertension: >95th percentile only in a physicians office or clinic Pediatrics 2004;114;555

Measurement Children >3 years old who are seen in a medical setting should have their BP measured The preferred method of BP measurement is auscultation Correct measurement requires correct cuff size Measurements >90th %tile with oscillometric devices needs repeated

Technique Sitting quietly for five minutes Avoid stimulant drugs and food Sitting upright with right arm supported at the level of the heart Right arm is preferred

Technique SBP is determined by the onset of the “tapping” Korotkoff sounds (K1) DBP is association with disappearance of Korotkoff sounds (K5) If K5 persists, then K4 should be used which is “muffling” of the sounds

Cuff Size Length of BP cuff bladder should be 80% of the circumference of the upper arm Width of BP cuff bladder should be at least 40% of the circumference of the upper arm If cuff is too small, BP value may be elevated If cuff is too large, BP value may be underestimated

Cuff Size

Special Circumstances What about younger children? Conditions Under Which Children <3 Years old Should Have BP Measured History of prematurity, VLBW, or other neonatal complication requiring intensive care Congenital heart disease (repaired or unrepaired) Recurrent urinary tract infections, hematuria, or proteinuria Known renal disease or urologic malformations Family history of congenital renal disease Solid-organ transplant Malignancy or bone marrow transplant Treatment with drugs known to raise BP other systemic illnesses associated with hypertension (neurofibromatosis, tuberous sclerosis, etc) Evidence of elevated intracranial pressure

Classification

Lifestyle modifications Cardiovascular Health Integrated Lifestyle Diet (CHILD-1) First stage dietary intervention for cardiovascular abnormalities Encourage maintenance of a healthy weight Encourage regular activity Decrease screen time Tobacco exposure/use counseling

Caloric Intake

Clinical Evaluation of Confirmed Hypertension History, including sleep history, family history, risk factors, diet, and habits such as smoking and drinking alcohol; physical examination H&P help focus subsequent evaluation All children with persistent BP 95th percentile: BUN, creatinine, electrolytes, Urinalysis +/- urine culture CBC Renal U/S Fasting lipid panel, fasting glucose Retinal exam and echocardiogram – Evaluate for end-organ damage Pediatrics 2004;114;555

Pediatrics 2004;114;555 Additional evaluation as indicated: Drug screen - History suggestive of possible contribution by substances or drugs. Polysomnography - History of loud, frequent snoring ABPM - ?white-coat HTN, and when other information on BP pattern is needed Young children with stage 1 hypertension and any child or adolescent with stage 2 hypertension Renovascular imaging Plasma renin determination Plasma and urine steroid levels Plasma and urine catecholamine levels Pediatrics 2004;114;555

Treatment Indications Symptomatic hypertension Secondary hypertension Hypertensive target-organ damage Diabetes (types 1 and 2) Persistent hypertension despite non-pharmacologic measures

Medical Management General principles Therapy should be initiated with a single drug Acceptable drug classes include ACE inhibitors, angiotensin-receptor blockers, β-blockers, calcium channel blockers, and diuretics Goal for treatment should be less than the 95th percentile If concurrent conditions are present, goal should be less than the 90th percentile Severe, symptomatic hypertension should be treated with IV meds

HTN Indications for referral: Preferably initial labwork/testing already started Secondary HTN – referral to appropriate subspecialist Stage 2 HTN? anyone you are not comfortable treating!

Cholesterol Screening Family history has been used historically History of coronary artery disease in a parent or grandparent Definition- heart attack, treated angina, interventions for coronary artery disease, stroke, or sudden cardiac disease Men less than 55 years of age Women less than 65 years of age Parents with elevated cholesterol

Screening Insensitive predictor May miss 30-60% of children with dyslipidemia CARDIAC project—Dr. Neal, WVU 20,266 fifth grade students in WV public school system Rate of abnormal LDL in children with a positive family history was similar to that found in children without a concerning family history

NHLBI 2011 Universal screening Selective screening First screening performed between 9 and 11 years of age Second screening performed between 17 and 21 Selective screening Between 2 and 8 years of age (see next slide) Between 12 and 16 years of age (if new risk factors identified)

Selective screening Special conditions Family history of premature CAD Parent with known dyslipidemia or total cholesterol > 240 mg/dL Smoker Hypertension BMI ≥ 95th %tile Diabetes (Type I or 2) Chronic kidney disease/ESRD/post-renal transplant Post-orthotopic heart transplant Kawasaki disease with current or regressed aneurysms Chronic inflammatory disease (SLE, JRA) HIV infection Nephrotic syndrome Kavey REW et al. Pediatrics 2011;128: S1-44

Screening Test Universal screening may be done with a fasting or nonfasting sample A fasting lipid panel is recommended for selective screening What is the difference?

Cholesterol Testing Fasting lipid profile Non-fasting lipid profile Total cholesterol (TC), HDL, and triglyceride levels (TG) directly measured LDL calculated LDL= (TC – HDL) – (TG/5) Non-fasting lipid profile Measures TC and HDL Non-HDL calculated Non-HDL= TC - HDL

Testing Non-HDL cholesterol seems to be predictive of persistent dyslipidemia than TC, LDL, or HDL in both children and adults No need for direct LDL measurement Most studies have shown that measurement of apolipoprotein B and apolipoprotein A-1 for universal screening provides not additional advantage Measurement of lipoprotein A is useful in the assessment of children with both hemorrhagic and ishchemic stroke

Normal Values

Lipid Levels in Children and Adolescents Cut points for a high or borderline high value are 95th and 75th percentile, respectively. Cut points for a low or borderline low value are 5th and 25th percentile, respectively Kwiterovich P, J Clin Endocrinol Metab 2008 S1-44 Kavey REW et al. Pediatrics 2011;128:

Confirmation Testing If the fasting lipid profile is abnormal, repeat should be measured in 2 weeks to 3 months If non-HDL screening is abnormal, fasting lipid profiles should be measured twice in 2 weeks to 3 months **Average value is used to determine the need for treatment

Controversy Previous guidelines had not recommended universal screening Other concerns Many patients may be harmed by screening Lack of evidence regarding treatment in children Cost Side effects of statins

Diet – Dyslipidemia/Overweight (CHILD-1) Total fat 25%-30% daily kcals –Saturated fat < 10 % daily kcals –Mono-and poly-unsaturated fats up to 20% daily calories Avoid trans fats Cholesterol < 300 mg daily Limit sweetened beverages >5 servings fruits & vegetables daily Fiber: Age + 5g/day (2-10 yrs) 14 g/1000kcal (11-21 yr) NCEP expert panel of blood cholesterol levels in children and adolescents. Pediatrics 1992;89:495-501.

Diet: Persistent High LDL-c After 3-6 months of low-saturated fat diet and LDL-c remains >130 mg/dL Reduce saturated fat intake to <7% of total calories Dietary cholesterol < 200 mg/d Meet with registered dietitian Soluble fiber 6 g/d for children 2–12 years 12 g/d for those ≥12 years Daniels SR, Pediatrics 2008

Diet - High Triglycerides Limit simple sugars and carbohydrates Increase fiber and complex carbohydrates Omega-3 fatty acids Ex: wild salmon, flaxseed, walnuts, winter squash EPA + DHA, 2-4 grams/day Hard to get through diet alone OTC or prescription Weight loss or stabilization Kris-Etherton PM et al, Circulation

Treatment Summary CHILD-1  CHILD-2 (LDL or TG) plus lifestyle modifications for 6 months Consider referral to dietician Exclude secondary causes Repeat fasting lipid profile Medical therapy may be recommended depending on the response Consult with a lipid specialist TG ≥ 500 mg/dL or LDL ≥ 250 Age < 10 years Any patient with whom you are uncomfortable managing!

SUMMARY BP screening for all kids >3yo younger if risk factors Cholesterol screening ages 9-11, then 17-21 Additional selective screening as needed For both BP and lipids: Confirm the diagnosis Evaluate for secondary causes Dietary/lifestyle modifications

References The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents. Pediatrics 2004;114;555 Kwiterovich P. Recognition and Management of Dyslipidemia in Children and Adolescents. J Clin Endocrinol Metab 2008 S1-44 Kavey REW et al. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: Summary Report. Pediatrics 2011;128 NCEP expert panel of blood cholesterol levels in children and adolescents. Pediatrics 1992;89:495-501 Daniels SR, Lipid Screening and Cardiovascular Health in Childhood. Pediatrics 2008;122;198-208. DOI: 10.1542/peds.2008-1349