hypertension - when to measure blood pressure in children and how to interpret what you find ä jan...

Hypertension - when to measure blood pressure in children and how to interpret what you find

Hypertension - when to measure blood pressure in children and how to interpret what you find

Jan Janda, Tomas SeemanJan Janda, Tomas Seeman

First Department of PaediatricsFirst Department of PaediatricsUniversity Hospital MotolUniversity Hospital Motol

Charles University, Prague, CZCharles University, Prague, CZ

Europaediatrics Europaediatrics Prague, October 20, 2003Prague, October 20, 2003

Definition of hypertensionDefinition of hypertension

Blood pressure higher than the 95th Blood pressure higher than the 95th percentil of normal values according the percentil of normal values according the age or body height and must be found at age or body height and must be found at least 3 times (different session, time gap least 3 times (different session, time gap at least weeks) at least weeks)

Exception:Exception: severe hypertension, then one severe hypertension, then one measurement sufficient, immediately measurement sufficient, immediately appropriate interventionappropriate intervention

How to evaluate and interpretthe blood pressure

How to evaluate and interpretthe blood pressure

In children always respect the age In children always respect the age (height values even better)(height values even better)

BP- BP- interpretation according standard interpretation according standard nomograms (percentile values)nomograms (percentile values)

Normal =under 90.percentileNormal =under 90.percentileHigh-normal=betweenHigh-normal=between 90.-95. “ 90.-95. “Hypertension= > 95. „Hypertension= > 95. „

Grading of hypertension Grading of hypertension

11. borderline HT diastolic BP up 5 mmHg. borderline HT diastolic BP up 5 mmHg

higher than higher than 95. percentile95. percentile

2. significant HT: diastolic BP 5-10 mmHg2. significant HT: diastolic BP 5-10 mmHg higher than higher than 95. percentile95. percentile

3. severe HT: diastolic BP 5-10 mmHg3. severe HT: diastolic BP 5-10 mmHg>> higher than higher than 95.p95.percentileercentile

Evaluation of the blood pressure in children

Evaluation of the blood pressure in children

NormNormal valuesal values:: 1. Second Task Force Report, 19871. Second Task Force Report, 1987 (age)(age)

2.2. de Man, 1991 (BP according the age, de Man, 1991 (BP according the age, height)height)

3. Update on the TFR, 1996 (age 3. Update on the TFR, 1996 (age +height)+height)

Pediatrics,1987, 79: 1-25, 1996, 98: 649-658

European Societies of Hypertension and Cardiology Recent recommendation 2003

European Societies of Hypertension and Cardiology Recent recommendation 2003

Guidelines committee recommendationsGuidelines committee recommendations published in published in Journal of Hypertension,Journal of Hypertension,

2003, 21, 1011-10532003, 21, 1011-1053 Position statement in the elderly, Position statement in the elderly,

diabetics, impaired renal functiondiabetics, impaired renal function

No special position statement in No special position statement in childrenchildren

USA-Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure

USA-Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure

JAMAJAMA, May 21, 2003, , May 21, 2003,

Volume 289, No 19, 2534-2573Volume 289, No 19, 2534-2573

The Seventh Report of JNC:The Seventh Report of JNC:

USA-guidelines, USA-guidelines, here a short section on here a short section on hypertension in children and adolescentshypertension in children and adolescents

stressing the non-pharmacological stressing the non-pharmacological intervention and healthy life-styleintervention and healthy life-style

Measurement of blood pressure in adults is a daily routine,but this easy procedure is unfortunately often omitted in children

Techniques of the blood pressure Techniques of the blood pressure measurement in children and measurement in children and

adolescentsadolescents

- - 1. 1. AccidentalAccidental: in pediatric office : in pediatric office (appropriate cuff –2/3 arm- lenght, the (appropriate cuff –2/3 arm- lenght, the width of the cuff is the rubber and not width of the cuff is the rubber and not the textile! the textile!

Sitting position, the right arm, at heart Sitting position, the right arm, at heart level, the child must be calm level, the child must be calm

Techniques of the blood pressure measurement in children and adolescents


A) Auscultation: systolic BP = Korotkoff 1A) Auscultation: systolic BP = Korotkoff 1

diastolic BP= Korotkoff 5 diastolic BP= Korotkoff 5

What is the „muffling phenomena“ ?What is the „muffling phenomena“ ?

B) Oscillometry =(systolic BP+ MAP) – B) Oscillometry =(systolic BP+ MAP) – diastolic BPdiastolic BP

C) Doppler-methodsC) Doppler-methods

Techniques of the blood pressure measurement

Techniques of the blood pressure measurement

Having found high blood pressure, Having found high blood pressure, please, please, always measure the BP in low always measure the BP in low extremitiesextremities. .

Normally, the BP in low extremities must Normally, the BP in low extremities must be higher than measuring the BP on be higher than measuring the BP on arms! arms! The reasonThe reason: in fact, the BP is the same, : in fact, the BP is the same, but using a relative narrow cuff (the but using a relative narrow cuff (the circumference of thigh is higher than that of circumference of thigh is higher than that of the arm) you will find false higher BP-values the arm) you will find false higher BP-values



22.. Home-measurement Home-measurement (children, parents)(children, parents) The same as the accidental measurement, The same as the accidental measurement,

but better results (elimination of the stress but better results (elimination of the stress in the office, frequent measurement in the office, frequent measurement

Motivation of the patient and his/her Motivation of the patient and his/her family!(family!(does increase the compliancedoes increase the compliance))

Ambulatory Blood Pressure Monitoring (ABPM)


3.3.ABPM=24-hours Blood Pressure MonitoringABPM=24-hours Blood Pressure Monitoring Oscillometry, special device, intermittent Oscillometry, special device, intermittent

measurement in given intervals. Better measurement in given intervals. Better correlation with direct intraarterial technique correlation with direct intraarterial technique and organ damageand organ damage

Detection of theDetection of the white-coat-hypertension and white-coat-hypertension and night-hypertension night-hypertension

Disadvantage: high price, some problems Disadvantage: high price, some problems measuring the BP in infants and toddlers. measuring the BP in infants and toddlers.

I. dk FNM 3

Typical circadiane BP-valuesTypical circadiane BP-valuessee the typical physiological dipping see the typical physiological dipping

during the nightduring the night

12 14 16 18 20 22 24 2 4 6 8 10 12 .12 14 16 18 20 22 24 2 4 6 8 10 12 .

hodin

MAP



ABPM should become a routine ABPM should become a routine procedure in all pediatric hospital procedure in all pediatric hospital departments. departments.

Nevertheless, it needs special skill and Nevertheless, it needs special skill and knowledge how to interprete the resultsknowledge how to interprete the results

For evaluation For evaluation special nomogramsspecial nomograms necessary, please do not take STFR-value!necessary, please do not take STFR-value!

Special nomograms availableSpecial nomograms available

How to interpret the ABPM-values? How to interpret the ABPM-values?

Special nomograms for ABPM availableSpecial nomograms for ABPM available:: Wuhl Elke et al: Distribution of 24-hours ambulatory blood Distribution of 24-hours ambulatory blood

pressure in children: normalized reference pressure in children: normalized reference values and role of body dimensions values and role of body dimensions

J Hypertens 2002, 20, (10):1995, p. 2007

Blood pressure depends on: Blood pressure depends on:

BP value at the initial measurement- BP value at the initial measurement- age, gender, height, weightage, gender, height, weight racial aspectsracial aspects endogenousendogenous factors: genetic factors: genetic

predispositionpredisposition exogenousexogenous factors: ecology, style of life factors: ecology, style of life

(diet, salt intake, body fitness, (diet, salt intake, body fitness, smoking..)smoking..)

Hypertension – Hypertension –

an important risk factor foran important risk factor for cardiovascular diseases, increases the morbidity cardiovascular diseases, increases the morbidity

and mortality (coronary ischemia, heart attacks, and mortality (coronary ischemia, heart attacks, cerebral strokes, hypertensive nephropathy.cerebral strokes, hypertensive nephropathy.Linkage with development of atherosclerosisLinkage with development of atherosclerosisVery often oligosymptomatic and Very often oligosymptomatic and underestimated as a „big killer“underestimated as a „big killer“

How important is the BP-control:How important

is the BP-control:

Decrease of BP= significant decrease Decrease of BP= significant decrease of morbidity and mortality (of morbidity and mortality (diastolic diastolic BP minus 5-10mmHg= coronary BP minus 5-10mmHg= coronary ischemia less 14%, cerebral strokes ischemia less 14%, cerebral strokes less 33-42%!!, mortality decrease less 33-42%!!, mortality decrease 40% (in adult patients with 40% (in adult patients with hypertension).hypertension). Unfortunately lack of Unfortunately lack of similar studies performed in similar studies performed in childhood and evaluated laterchildhood and evaluated later

What is „tracking phenomena“ What is „tracking phenomena“

BP in children follows the same percentile until BP in children follows the same percentile until the maturity (hypothesis= hypertension in the maturity (hypothesis= hypertension in adulthood starts in childhood)adulthood starts in childhood)

Nevertheless, this statement limited, Nevertheless, this statement limited,

particularly in younger children, „crossing particularly in younger children, „crossing over“ possible over“ possible

Late sequalae of hypertension Late sequalae of hypertension

Dependent on:Dependent on: Cause of hypertension Cause of hypertension Range of BP (mild, asymptomatic, severe Range of BP (mild, asymptomatic, severe

forms, organ damageforms, organ damage Age when hypertension arised Age when hypertension arised Hypertension intermittent, lasting, day Hypertension intermittent, lasting, day

and/or night hypertension and/or night hypertension

Incidence of hypertensionIncidence of hypertension

Rate ca 1% of all children ! Rate ca 1% of all children ! But in adulthood 10-20%, in adults ca 90% But in adulthood 10-20%, in adults ca 90%

essentialessential hypertensionhypertension The spectrum of causes in children is quiet The spectrum of causes in children is quiet

differentdifferent Secondary forms prevail in younger Secondary forms prevail in younger

children, these are potentionally accesible children, these are potentionally accesible for an intervention, so diagnostics in early for an intervention, so diagnostics in early age necessary!age necessary!

Causes of hypertension in children

Renoparench.60%

Renovask10%

Kardiální10%

Esenciální18% Endokrinní

2%

Essential hypertension in childrenEssential hypertension in childrenDiagnosis „per exclusionem“ Diagnosis „per exclusionem“

(excluding the secondary forms(excluding the secondary forms) )

Etiopathogenesis?:hormonal-metabolicEtiopathogenesis?:hormonal-metabolic

syndrome, insulin resistance, obesity, NaCl syndrome, insulin resistance, obesity, NaCl intake, body fitness, smoking, style of life, intake, body fitness, smoking, style of life, endogenous factors (genes, ACE + EXO endogenous factors (genes, ACE + EXO factorsfactors

do 10 adol. 50 let

výskyt20%

2%1% 0%20%

do 10 adol. 50 let

výskyt

Essential hypertension in childrenEssential hypertension in children

1. Border line HT or mild HT1. Border line HT or mild HT2. Positive family history2. Positive family history3. Obesity3. Obesity

Adolescents, high heart rate, the Adolescents, high heart rate, the measured values vary considerable measured values vary considerable during the follow-upduring the follow-up

Clinical picture of hypertensionClinical picture of hypertension

Symptoms vary, very often asymptomatic Symptoms vary, very often asymptomatic coursecourse

Symptoms depends on : Symptoms depends on : 1. age1. age 2. grading of hypertension2. grading of hypertension 3. 3.

cause of hypertension cause of hypertension Often symptoms do not lead directly to Often symptoms do not lead directly to

suspection for hypertension suspection for hypertension

Clinical picture of hypertension according the age (older children)Clinical picture of hypertension

according the age (older children)

Nausea, vomiting, Nausea, vomiting, headache (30%)- headache (30%)- occipital occipital

hypertensive encephalopathy, hypertensive encephalopathy, visus impairment, fatigue, visus impairment, fatigue,

irritability, irritability, epistaxis, epistaxis, abdominal pain abdominal pain

Work-up of a patient with hypertension


According the historyAccording the history grading of HTgrading of HT age, organ damage,age, organ damage, physical findingsphysical findings Aim: detect the primary cause and to Aim: detect the primary cause and to

treat causallytreat causally



Basic physical examination:Basic physical examination: repeated BP-measurement (standard repeated BP-measurement (standard

setting), measuring BP in all 4 extremitiessetting), measuring BP in all 4 extremities The evaluation mentioned earlier: The evaluation mentioned earlier:

In individuals not appropriate for ageIn individuals not appropriate for age= = better to take thebetter to take the body height!body height!

„„Updated task force report“Updated task force report“



Cardiac murmers (coarctation, Botall)Cardiac murmers (coarctation, Botall) Heart rate (tachycardia in hyperthyreosis Heart rate (tachycardia in hyperthyreosis

and feochromocytoma)and feochromocytoma) abdomen: enlargemnent of kidneysabdomen: enlargemnent of kidneys abdominal murmers (aortic stenosis, abdominal murmers (aortic stenosis,

stenosis of renal arteries)stenosis of renal arteries)

Laboratory investigationLaboratory investigation

I. step:- basic investigationI. step:- basic investigation Blood count, urinalysis plus sediment, Blood count, urinalysis plus sediment,

urine culture urine culture

Serum creatinine (GFR according Schwartz) Serum creatinine (GFR according Schwartz)

cholesterol (HDL, LDL, triglyceridy, ELFOcholesterol (HDL, LDL, triglyceridy, ELFO lipoproteinslipoproteins, blood sugar, Astrup, blood sugar, Astrup

Further investigationFurther investigation

Renal function (GFR, standardized concentration capacity test (DDAVP), proteinuria, microalbuminuria, markers of

tubular damagechest X- ray, ECG

Fundoscopy Renal sonography, ABPM !!

II.step- targeted examination:II.step- targeted examination: Renal cause suspected-radionuclide

investigation : MAG3MAG3 (tubular functions, obstruction,

obstruktion, separated renal functions (hypo-dysplasieDTPA DTPA (GFR, renal perfusion)(GFR, renal perfusion)

DMSADMSA (renal scarring, ischemic foci, (renal scarring, ischemic foci, separated assessment)separated assessment)

Treatment of hypertension Treatment of hypertension Secondary hypertension:

Causal - according the diagnosis Renoparenchymatous: therapy of N, PN, VUR,

obstructive uropathy- nephrectomy of dysplastic kidney

renovascular: PTA, cardiosurgery, feochromocytoma, adenoma- resection+ symptomatic treatment with the aim to ……… control the increased blood pressure

Treatment of hypertension Treatment of hypertension

I. non-pharmacological approachmild hypertension, mostly essential forms:

recommended also in high-nornal HT

According the risk factors:

1. Weight reduction (proved effect)

2. Body fitness (dynamic, sports allowed when HT controlled

3. Diet

Salt restriction (very often really a „salt Salt restriction (very often really a „salt addiction“-salt as a drug!), increased addiction“-salt as a drug!), increased potassium intake (fruits, vegetables),potassium intake (fruits, vegetables), caloric restriction in obese patient, restriction of fat intake

Combination of the given factors !!

= healthy style of life

I. non-pharmacological intervention

I. non-pharmacological intervention

II. Pharmacological interventionPrevious attempts not succesful,

but please do continue them! Symptomatic treatment always in severe hypertension and if organ damage already present !

Pharmacological interventionPharmacological intervention

Aim : BP below the 90.percentile- minimal dosage which are effective, minimal adverse effects, parents and patient compliance

I.step: monotherapy, low dosage

II.step- increase the dosage

III.step- combination of 2 drugs

Medicaments in hypertension Medicaments in hypertension

What drug is the best one for children ? ? ? ? ? ? ? ? ? ?

There are no controlled pediatric studies with different antihypertensive drugs

Choices similar as in adults, but Choices similar as in adults, but effective doses effective doses for children are often smaller and should be for children are often smaller and should be adjusted stepwise carefully.adjusted stepwise carefully.

ACEI- and angiotensin receptor-blockers should ACEI- and angiotensin receptor-blockers should not be used in pregnant and sexually active girls.not be used in pregnant and sexually active girls.

Conclusions I. Conclusions I.

Every child with hypertension must be examined with the aim to detect the cause of high blood pressure

When possible, the causal therapy The causes of high BP in children are age-

dependent! During early childhood secondary hypertension prevails (mostly due to nephro-/uropathy), later increased incidence of essential hypertension

Conclusions II.Conclusions II.

Blood pressure measurement must become a Blood pressure measurement must become a routine on the level of pediatric primary care routine on the level of pediatric primary care

also in preschool children! also in preschool children! Standardized evaluation using nomogramsStandardized evaluation using nomograms

The best solution: including the nomograms in theThe best solution: including the nomograms in the„„Health and Vaccination Records“!Health and Vaccination Records“!

Instruction in families at risk for Instruction in families at risk for cardiovascular morbidity/mortality (high-cardiovascular morbidity/mortality (high-

normal values in children!) normal values in children!) Family compliance essential!Family compliance essential!

Conclusions III.Conclusions III.

Essential hypertension Essential hypertension

does not start with the 18th birthday!!! does not start with the 18th birthday!!! Special care in adolescents with positive Special care in adolescents with positive

familial history, particulary in familial history, particulary in individuals with „high normal values“individuals with „high normal values“

In this age category avoid the risk factors In this age category avoid the risk factors (smoking, obesity, high salt iand fat (smoking, obesity, high salt iand fat intake)intake)

ABPM= ABPM= routine in pediatric hospital careroutine in pediatric hospital care

Conclusions IV.Conclusions IV.

The The primary care pediatricianprimary care pediatrician´s role ´s role and his judgement concerning the and his judgement concerning the prevention, detection, evaluation and prevention, detection, evaluation and treatment of hypertension remains treatment of hypertension remains paramountparamount

EmpathyEmpathy of pediatricians, families of pediatricians, families and children/adolescents builds0 and children/adolescents builds0 trust and is a potent motivator!trust and is a potent motivator!

Thank you for your Thank you for your attentionattention

hypertension - when to measure blood pressure in children and how to interpret what you find ä jan...

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