1 / 45

Pediatric Hypertension Update

Pediatric Hypertension Update. WV AAP Annual Spring Meeting 3/29/2019 Jack Stines, M.D. I have no disclosures. Objectives. Review the 2017 American Academy of Pediatrics (AAP) guideline for screening and management of high blood pressure in children and adolescents. Pediatric Hypertension.

adanna
Download Presentation

Pediatric Hypertension Update

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  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)

  7. 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

  8. New Normative BP Tables

  9. Simplified Screening Table

  10. 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

  11. 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

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

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

  14. 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

  15. 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

  16. 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

  17. 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

  18. 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

  19. 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

  20. 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

  21. 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)

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

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

  24. 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

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

  26. 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

  27. 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

  28. 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

  29. 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

  30. 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

  31. 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

  32. 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

  33. 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

  34. 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

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

  36. 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

More Related