1. Monday, July 25 th, 2011

2.  Diagnostic Evaluation  COST  Confirm the diagnosis  Organize a diagnostic approach  Determine the Severity of the HTN  Treat the HTN effectively

3.  Suspect when the BP reading is high for the height, age, and sex of the child  Confirmed when a high reading is obtained at three or more separate office visits about 1 week apart

4.  Ensure proper BP cuff size  Bladder should encircle the arm by at least 80%

6.  MONSTER  Medications  Obesity  Neonatal history  Symptoms or signs  Trends in the family  Endocrine or renal

7. **Remember, amphetamines, corticosteroids, contraceptives, cyclosporine, OTC allergy and cold medicine and licorice can cause HTN

8. BMI > 95% 3 to 5 times more likely to have hypertension Can have obstructive sleep apnea syndrome (OSAS) Causes significantly higher diastolic BPs

13.  Evaluation is guided by history and physical  Biochemical and imaging studies are used to address three primary organ systems: endocrine, renal, and cardiovascular

16.  High uric acid is associated with high BP readings in childhood that may persist into adulthood (Bogalusa Heart Study)  Strong relationship between uric acid and essential HTN (found in 89%, but only 30% with secondary HTN, none with white-coat HTN)

17.  Combo of magnitude of BP elevation and presence of LVH on echo are proof of sustained HTN  Cardiac hypertrophy is major indication for therapy  Finding of LVH suggests risk for future CV disease

18.  Nonpharmacologic treatment  Lifestyle modifications or environmental changes must be implemented or at least attempted!  Reducing sodium intake  Physical activity  If significant essential or severe HTN, avoid weight lifting, body building, and strength training  Restriction based on the possibility of catastrophic event

19.  Goal is normalization or near-normalization of BP based on age, sex, and height using a drug regimen that causes minimal adverse effects  Consider starting with one drug and maximizing dose before adding a second agent

20.  First-line  ACE inhibitors (ex: Captopril, Enalpril)  SE = renal impairment, hyperkalemia, neutropenia, anemia, dry cough, angioedema  Angiotensin receptor blockers  SE = renal impairment, hyperkalemia, neutropenia, anemia  Calcium channel blockers (ex: Nifedipine, Isradipine)  SE = peripheral edema, dizziness, nausea, headache, flushing, weakness

21.  Second-line therapy  Beta-blockers  Central alpha agonists (Clonidine)  Vasodilators (Hydralazine, Minoxidil)  Diuretics

22.  1.  E. Schedule 2 subsequent visits to measure BP  2.  A. Echocardiography  3.  B. Hyperkalemia  4.  D. Perform renal ultrasonography

23. Noon conference is Inpatient ID with Dr. Begue