Management of High Blood Pressure in Children and Adolescents: Recommendations of the European Society of Hypertension

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Management of High Blood Pressure in Children and
Adolescents Recommendations of the European
Society of Hypertension

• Empar Lurbe Chairperson Renata Cifkova J
  Kennedy Cruickshank Michael J Dillon Isabel
  Ferreira Cecilia Invitti Tatiana Kuznetsova
  Stephane Laurent Ex officio Giuseppe Mancia
  Ex officio Francisco Morales-Olivas Wolfgang
  Rascher Josep Redon Franz Schaefer Tomas
  Seeman George Stergiou Elke Wühl Alberto
  Zanchetti

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Hypertension in Children and Adolescents
Recommendations of the ESH

• Introduction and purpose
• Definition and classification
• Diagnostic evaluation
• Preventive measures
• Evidence for therapeutic management
• Therapeutic strategies
• Therapeutic approaches under special conditions
• Treatment of associated risk factors

• 9. Screening of secondary forms
• 10. Long-term follow-up
• 11. Future research
• 12. Implementation of guidelines
• 13. Bibliography
• Figures
• Tables
• Boxes

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Introduction and Purpose (I)
Introduction and Purpose

• There is growing evidence that children and
  adolescents with mild BP elevation are much more
  common than was thought in the past
• Longitudinal studies have demonstrated that BP
  abnormalities in those age ranges do not
  infrequently translate into adult hypertension
• Hypertension in children and adolescents has
  gained ground in CV medicine thanks to the
  progress made in several areas of
  pathophysiological and clinical research

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Introduction and Purpose (II)
Introduction and Purpose

• The remoteness of cardiovascular events from the
  BP values of many years before makes the
  relationship between those BP values and the
  events difficult to establish
• Large intervention studies are lacking, and
  therefore cannot provide hints about cutoffs for
  evidence-based recommendations
• Many of the classifications and recommendations
  in children are based on statistical
  considerations and are the result of assumptions
  or extrapolations from evidence obtained in adults

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Characteristics of blood pressure
Introduction and Purpose

• Blood pressure increases during growth and
  maturation
• Adolescence is a fast growth period during which
  body mass and BP change rapidly
• Reference BP values over the last few decades
  have been referred to as ones specific for sex,
  age and/or height

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Definition and classification
Definition and classification
SBP and/or DBP Percentile
Normal lt90th
High-normal 90th to lt95th 120/80 even if below 90th percentile in adolescents
Stage 1 hypertension 95th percentile to the 99th percentile plus 5 mmHg
Stage 2 hypertension gt99th percentile plus 5 mmHg
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Diagnostic algorithm of hypertension
Definition and classification
SBP and/or DBP
ltP90th
gtP90th
Repeated measurements
NORMOTENSION
P95th
ltP90th
P90-95th
FOLLOW-UP
NORMOTENSION
HYPERTENSION
Evaluation for etiology and organ damage
Repeated measurements
Figure 1
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Blood pressure measurement
Diagnostic evaluation

• The recommended method is auscultatory
• Use K1 for systolic BP and K5 for diastolic BP
• If the oscillometric method is used, the monitor
  needs to be validated for this age group
• If hypertension is detected by the oscillometric
  method, it needs to be confirmed using the
  auscultatory method
• Use the appropriate cuff size according to arm
  width
• Children above 3 years of age who are seen in a
  medical setting should have their BP measured
• In younger children, BP should be measured under
  special circumstances that increase the risk for
  hypertension

Box 1
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Indications for 24-hour ABPM
Diagnostic evaluation

• During the process of diagnosis
• Confirm hypertension before starting
  antihypertensive drug treatment
• Type 1 diabetes
• Chronic kidney disease
• Renal, liver or heart transplant
• During antihypertensive drug treatment
• Evaluation of refractory hypertension
• Assessment of BP control in children with organ
  damage
• Symptoms of hypotension
• Clinical trials
• Other clinical conditions
• Autonomic dysfunction
• Suspicion of catecholamine-secreting tumours

Box 2
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Evaluation of organ damage
Diagnostic evaluation

• Organ damage is common and LV hypertrophy is the
  most prominent type
• Echocardiography should be performed. Left
  Ventricular Hypertrophy is an indication to
  initiate or intensify antihypertensive therapy
• Microalbuminuria is recommended for routine
  clinical use
• Carotid intima-media thickness, arterial
  stiffness, retinal and CNS assessment are not
  recommended for routine clinical use

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Evaluation for Secondary Hypertension
Screening for secondary forms

• Very young children with Stage 1 or Stage 2
  hypertension
• Children or adolescents with Stage 2 hypertension

Age-distribution of hypertension etiologies
gt 10 years Essential Hypertension Renal
Parenchymal Disease Exogenous Hypertension
(drugs) Endocrine Disorders Coarctation of the
aorta Mendelian Genetic Disorders
lt 1 month Renal arterial thrombosis Congenital
renal disease Umbilical canalization Bronchopulmon
ary dysplasia

• gt1 month to lt6 years
• Renal parenchymal disease
• Coarctation of the aorta
• Renovascular disease

• gt 6 years to 10 years
• Renal parenchymal disease
• Renovascular disease
• Essential hypertension

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Life style recommendations to reduce high BP
values
Preventive measures
GOAL
Maintain or achieve BMI lt85th
GENERAL RECOMMENDATIONS
Moderate to vigorous physical aerobic activity 40 minutes, 3-5 days/week and avoid more than 2 hours daily of sedentary activities
Avoid intake of excess sugar, excess soft drinks, saturated fat and salt and recommend fruits, vegetables and grain products
Implement the behavioural changes (physical activity and diet) tailored to individual and family characteristics
Involve the parents/family as partners in the behavioural change process
Provide educational support and materials
Establish realistic goals
Develop a health-promoting reward system
Competitive sports participation should be limited only in the presence of uncontrolled stage 2 hypertension
Box 6
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When to initiate antihypertensive treatment
Evidence for therapeutic management
Life threatening hypertension
High-normal BP
Hypertension
One or more of the following conditions Symptomat
ic Secondary Organ damage Diabetes
NO
YES
Nonpharmacological treatment
Pharmacological treatment
Figure 3
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Evidence for therapeutic management
Blood pressure targets

• In general
• BP lt90th age, sex and height specific percentile
• Chronic kidney disease
• BP lt75th percentile in children without
  proteinuria and lt50th percentile in cases of
  proteinuria
• 24-hour ABP strongly recommended.
• Goals lt75th percentile in children without
  proteinuria and lt50th percentile in cases of
  proteinuria

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Therapeutic strategies
How to initiate antihypertensive treatment
Particular conditions Stage 2 Chronic kidney
disease Secondary
All hypertensives
Monotherapy (low dose 4-8 w)
No response
Monotherapy (full dose)
No response
Switch drug
Side effects
No response
Combination therapy
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Therapeutic strategies
Antihypertensive agents with efficacy and safety
studies in children and adolescents
Class Efficacy studies
Diuretics Clorthalidone, HCZT
b-blockers Atenolol, Metoprolol, Propanolol
CCB Amlodipine, Felodipne, Isradipine
ACEi Captopril, Enalapril, Fosinopril, Lisinopril, Quinapril, Ramipril
ARB Candesartan, Irbesartan, Losartan, Valsartan
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Long-term follow-up
Long-term follow-up

• Initial frequent follow up visits to monitor
• BP control, organ damage
• Side effects of treatment
• Other reversible risk factors
• Once BP stable and in target range, frequency of
  visits can be reduced
• Home monitoring of BP or 24 hour ABPM can
  facilitate follow up assessments
• Dependent on the underlying cause of
  hypertension, further investigative procedures
  may be indicated to monitor success of surgical
  intervention or medical treatment

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Future research
Future research

• Develop accurate non-mercury sphygmomanometer for
  auscultatory BP measurement and oscillometric BP
• Reference values for office, home and ambulatory
  BP based on a European pediatric population
• Increase knowledge in the use of out-of-office BP
  measurements
• Collect information about early organ damage to
  refine risk stratification and use the
  information to set intermediate objectives during
  treatment

Box 10
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Future research
Future research

• Conduct controlled studies with antihypertensive
  drugs in order to improve knowledge about
  specific benefits and disadvantages of BP
  lowering agents and establish adequate doses
• Conduct large, long term randomized therapeutic
  trials using onset of organ damage to obtain
  information about when to initiate
  antihypertensive drug treatment and about BP
  goals

Box 10
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Implementation of Guidelines
Implementation guidelines

• Joint efforts should be started so as to promptly
  implement the guidelines
• Synergistic actions at various levels (learned
  societies, expert committees, GPs, pediatricians,
  nurses and other healthcare providers, school,
  parents and policy makers) should be encouraged
  to participate
• The role of learned Societies, particularly ESH,
  is crucial for spreading the guidelines and the
  acceptance by National Hypertension Societies and
  Leagues
• Active support of research is necessary in order
  to gain knowledge helpful to future developments
  in the field, so studies that are recommended
  should be promptly initiated

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Hypertension in Children and Adolescents
Recommendations of the European Society of
Hypertension

• Renata Cifkova, Prague
• J Kennedy Cruickshank, Manchester
• Michael J Dillon, London
• Isabel Ferreira, Maastricht
• Cecilia Invitti, Milan
• Tatiana Kuznetsova, Leuven
• Stephane Laurent, Paris - Ex officio
• Empar Lurbe, Valencia Chair

• Giuseppe Mancia, Milan - Ex officio
• Francisco Morales-Olivas, Valencia
• Wolfgang Rascher, Erlangen
• Josep Redon, Valencia
• Franz Schaefer, Heidelberg
• Tomas Seeman, Prague
• George Stergiou, Athens
• Elke Wühl, Heidelberg
• Alberto Zanchetti, Milan