Pediatric Hypertension Update

1. Pediatric Hypertension Update WV AAP Annual Spring Meeting 3/29/2019 Jack Stines, M.D.

2. I have no disclosures

3. Objectives • Review the 2017 American Academy of Pediatrics (AAP) guideline for screening and management of high blood pressure in children and adolescents

4. Pediatric Hypertension • Prevalence of clinical HTN in children and adolescents is ~3.5% • Higher in overweight and obese children • High BP in childhood increases the risk of adult CV disease

5. 2004 2017 -Flynn et al. Pediatrics 2017; 140 (3):e20171904

6. AAP Guidelines 2017 • Comprehensive document • Rigorous, evidenced based methodology • Primarily aimed at outpatient management • Key action statements (30) • Consensus opinion recommendations (27)

8. Significant Changes • Elevated BP replaces prehypertension • New normative tables • Introduction of simplified screening table • Simplified BP classification for adolescents • Limited recommendations for screening • Streamlined recommendations for initial evaluation and management • Expanded role of ambulatory blood pressure monitoring (ABPM) • Revised recommendations for echocardiography

10. New Normative BP Tables

11. Simplified Screening Table

12. BP Measurement Frequency • Annual BP measurement in children and adolescents ≥3 years of age at well-child checks • Younger infants and children should have BP measured if at increased risk

14. BP Measurement Frequency • Some children and adolescents ≥3 years of age should have their BP measured at every health encounter • Obesity • Renal disease • History of aortic arch obstruction or coarctation • Diabetes • Medications

19. Diagnosis • Diagnosis of hypertension requires ausculatory confirmed BP readings ≥95th percentile on 3 different visits

20. Management of Elevated BP • Recommend lifestyle interventions • Repeat measurement in 6 months • Nutrition/weight management referral should be considered

21. Management of Elevated BP • If BP remains at the elevated level after 6 months • Upper and lower extremity BP should be checked (RA, LA, leg) • Lifestyle counseling should be repeated • Repeat in 6 months at next well-child visit by auscultation

22. Management of Elevated BP • If BP continues at the elevated BP level after 12 months (after three ausculatory measurements) • ABPM should be ordered (if available) • Diagnostic evaluation should be conducted • Consider subspecialty referral (nephrology or cardiology) • If BP normalizes at any point, return to annual screening at well-child visits

23. Stage I HTN Management • If the BP reading is at stage I HTN level and the patient is asymptomatic • Provide lifestyle counseling • Recheck BP in 1-2 weeks by auscultation

24. Stage I HTN Management • If the BP reading remains at stage I level • Upper and lower extremity BP should be checked • Repeat BP in 3 months by auscultation • Nutrition/weight management referral should be considered

25. Stage I HTN Management • If BP continues to be at stage I HTN level after 3 visits • ABPM should be ordered (if available) • Diagnostic evaluation should be conducted • Treatment should be initiated • Subspecialty referral should be considered

26. Stage 2 HTN Management • If the BP reading is at stage 2 HTN level • Upper and lower extremity BP should be checked • Lifestyle recommendations given • Repeat within one week • Alternatively, the patient could be referred to subspecialty care within 1 week

27. Stage 2 HTN Management • If the BP reading is still at stage 2 HTN level when repeated • Diagnostic evaluation including ABPM • Treatment should be initiated • Referral to subspecialty care within 1 week

28. Stage 2 HTN Management • If the BP reading is at stage 2 HTN level and the patient is symptomatic or the BP is >30 mmHg above the 95th percentile or >180/120 in an adolescent • Refer to an immediate source of care (ED)

30. Evaluation • Goals • Differentiate primary from secondary HTN • Identify comorbidities • Identify children who should be treated with medical therapy

31. Evaluation • History • Perinatal, nutritional, physical activity, psychosocial, family • Physical examination • Laboratory tests • Imaging procedures

32. Primary and Secondary HTN • Primary HTN is more common • Older age • Family history • Overweight/Obese • Severity of BP elevation has not differed in some studies • Systolic HTN more predictive of primary HTN • Diastolic HTN more predictive of secondary HTN

33. Secondary Causes • Renal/Renovascular • Coarctation • Endocrine HTN • Environmental • Neurofibromatosis • Medication related • Monogenic HTN

34. Evaluation • Children and adolescents ≥6 years of age do not require extensive evaluation for secondary causes of HTN if… • Positive family history of HTN • Overweight or obese • Do not have history or physical examination findings suggestive of a secondary cause of HTN

36. Ambulatory BP Monitoring (APBM) • Should be performed for confirmation of HTN in children and adolescents with elevated BP for one year or diagnosed stage I HTN • Limited to children ≥5 years of age • Should be strongly considered in children and adolescents with high risk conditions • Recommended in suspected white coat hypertension

37. Doppler Renal Ultrasound • No evidence based criteria for the identification of children and adolescents who may be more likely to have RAS (renal artery stenosis) • Doppler renal ultrasound may used as a noninvasive screening study for RAS in normal weight children and adolescents ≥8 years of age • CT/MRI may also be used

38. Electrocardiography • Clinicians should NOT perform electrocardiography in hypertensive children and adolescents being evaluated for LVH • High specificity, low sensitivity • PPV of EKG for evaluating LVH is extremely low

39. Echocardiography • Recommended to assess for cardiac target organ damage (LV mass, geometry, and function) at the time of consideration of pharmacologic treatment of HTN • LVH should be defined as LV mass >51 g/m2.7 for children and adolescents older than 8 years • Or LV mass >115 g/BSA for boys and > 95 g/BSA for girls • Repeat studies may be performed may be considered to monitor improvement or progression of target organ damage

40. Lifestyle Modifications • DASH diet • High in fruits, vegetables, low-fat milk products, whole gains, fish, poultry, nuts, and lean red meat • Physical activity • Moderate to vigorous physical activity 3-5 days per week for 30-60 min • Weight loss • Stress reduction

41. Medical Therapy • Children who remain hypertensive despite a trial of lifestyle modifications • Symptomatic HTN • Stage 2 HTN • Any stage of HTN associated with CKD or diabetes mellitus

42. Medical Therapy • ACE inhibitor, ARB, long-acting calcium channel blocker, or thiazide diuretic • Β-blockers not recommended as initial treatment • Single agent preferred • ACE inhibitor or ARB in CKD, proteinuria, or diabetes mellitus

43. Medical Therapy • Titrate every 2-4 weeks using home BP measurements • Patient should be seen every 4-6 weeks until BP has normalized • Second agent can be added and titrated as needed • Evaluate control with ABPM

44. Medical Therapy • Treatment goal with nonpharmacologic and pharmacologic therapy • <90th percentile in younger children • <130/80 in adolescents ≥13 years of age

45. Summary • Annual BP measurement at 3 years of age in healthy children • Best BP measurement practices important • New BP classifications and normative tables • Lifestyle modification first line • Medication may be necessary • Refer to subspecialty care as needed