Effects of childhood primary hypertension on carotid intima media thickness: a matched controlled study

Stress-induced cardiovascular reactivity and atherogenesis in adolescents

OBJECTIVE

To examine the association between cardiovascular reactivity to a set of psychological stressors and carotid artery intima-media thickness, a marker of subclinical cardiovascular disease in healthy adolescents.

METHODS

Participants were 25 boys and 23 girls age 14.2 ± 0.9 years who were measured for heart rate (HR), systolic (SBP) and diastolic (DBP) blood pressure reactivity to mirror-tracing, reaction time, speech preparation and ad lib speech tasks and for common carotid artery intima-media thickness. Sequential regression analyses were used to establish the incremental increase in R(2)(R(inc)(2)) for the prediction of intima-media thickness due to cardiovascular reactivity independent of age, BMI percentile, sex, socioeconomic status, and resting HR or BP.

RESULTS

SBP reactivity while preparing (β=0.0019, R(inc)(2)=0.09) and giving the speech (β=0.0014, R(inc)(2)=0.10) and an aggregate reactivity score based on all 4 tasks (β=0.0026, R(inc)(2)=0.11) independently predicted (p ≤ 0.05) mean carotid artery intima-media thickness. Neither DBP reactivity nor HR reactivity during any task were independent predictors of intima-media thickness.

CONCLUSION

Stress-induced cardiovascular reactivity, and especially SBP reactivity, is associated with carotid intima-media thickness and the early pathogenesis of cardiovascular disease. The use of an aggregate stress reactivity index provides a more reliable reflection of trait SBP reactivity to psychological stress and increases the confidence that youth with greater cardiovascular stress reactivity may indeed have greater progression of subclinical cardiovascular disease.

Obesity hypertension in adolescents: epidemiology, evaluation, and management

The prevalence of hypertension among all adolescents is approximately 3.5%, with somewhat higher rates of prehypertension. Obesity affects approximately 20% of adolescents in the United States, and the prevalence of hypertension is much higher among obese adolescents compared with nonobese adolescents. As in other populations, the evaluation of elevated blood pressure in obese adolescents should begin with a confirmation of the blood pressure elevation, followed by a focused diagnostic work-up to detect possible secondary causes of hypertension. Primary therapy for obesity-related hypertension in adolescents begins with weight loss, and may include antihypertensive medications if target-organ damage or other indications for drug therapy are present. The emphasis of management should be reduction of future cardiovascular risk.

Office, ambulatory and home blood pressure measurement in children and adolescents

There is an increasing interest in pediatric hypertension, the prevalence of which is rising in parallel with the obesity epidemic. Traditionally the assessment of hypertension in children has relied on office blood pressure (BP) measurements by the physician. However, as in adults, office BP might be misleading in children mainly due to the white coat and masked hypertension phenomena. Thus, out-of-office BP assessment, using ambulatory or home monitoring, has gained ground for the accurate diagnosis of hypertension and decision-making. Ambulatory monitoring is regarded as indispensable for the evaluation of pediatric hypertension. Preliminary data support the usefulness of home monitoring, yet more evidence is needed. Office, ambulatory and home BP normalcy tables providing thresholds for diagnosis have been published and should be used for the assessment of elevated BP in children.

Prevalence of elevated blood pressure and association with obesity in egyptian school adolescents

Aim. To investigate the relationship between high blood pressure (HBP) and obesity in Egyptian adolescents. Methods. A cross-sectional study of 1500 adolescents (11–19 years) in Alexandria, Egypt, was conducted. Resting BP was measured and measurements were categorized using the 2004 fourth report on blood pressure screening recommendations. Additional measures included height, weight, and waist and hip circumferences. Obesity was determined based on BMI, waist circumference (WC) and waist-to-hip ratio (WHR), and waist-to-height ratio (WHtR) indicators. Crude and adjusted odds ratios were used as measures of association between BP and obesity. Results. Prevalence rates of prehypertension and hypertension were 5.7% and 4.0%, respectively. Obesity was seen in 34.6%, 16.1%, 4.5%, and 16.7% according to BMI, WHR, WC, and WHtR, respectively. Adjusting for confounders, HBP was significantly associated with overall obesity based on BMI (OR = 2.18, 95%, CI = 1.38-3.44) and central obesity based on WC (OR = 3.14, 95%, CI = 1.67-5.94). Conclusion. Both overall obesity and central obesity were significant predictors of HBP in Egyptian adolescents.

Relationship of home blood pressure with target-organ damage in children and adolescents

The objective of this study was to compare home blood pressure (HBP) vs. ambulatory (ABP) and clinic (CBP) measurements in terms of their association with target-organ damage in children and adolescents. A total of 81 children and adolescents (mean age 13 ± 3 years, 53 boys) referred for elevated CBP had measurements of CBP (1 visit), HBP (6 days) and ABP (24-h). Seventy-six participants were also assessed with carotid-femoral pulse wave velocity (PWV) and 54 with echocardiography. Average CBP was 122.1 ± 15.1/71 ± 12.9 mm Hg (systolic/diastolic), HBP 121.3 ± 11.5/69.4 ± 6.6 mm Hg and 24-h ABP 118.9 ± 12/66.6 ± 6.1 mm Hg. Left ventricular mass (LVM) was correlated with systolic blood pressure (BP) (coefficient r = 0.55/0.54/0.45 for 24-h/daytime/nighttime ABP, 0.53 for HBP and 0.41 for CBP; all P< 0.01). No significant correlations were found for diastolic BP. PWV was also significantly correlated with systolic BP (r = 0.52/0.50/0.48 for 24-h/daytime/nighttime ABP, 0.50 for HBP and 0.47 for CBP; all P < 0.01). Only diastolic ABP and HBP were significantly correlated with PWV (r = 0.30 and 0.28, respectively, P<0.05). In multivariate stepwise regression analysis (with age, gender, body mass index [BMI], clinic, home and 24-h ambulatory systolic/diastolic BP and pulse pressure, clinic, home and 24-h heart rate as independent variables), PWV was best predicted by systolic HBP (R(2) = 0.22, beta ± s.e. = 0.06 ± 0.01), whereas LVM was determined (R(2) = 0.67) by 24-h pulse pressure (beta = 1.21 ± 0.41), age (beta = 2.93 ± 1.32), 24-h heart rate (beta = -1.27 ± 0.41) and BMI (beta = 1.78 ± 0.70). These data suggest that, in children and adolescents, ABP as well as HBP measurements appear to be superior to the conventional CBP measurements in predicting the presence of subclinical end-organ damage.

Obesity and associated cardiovascular risk factors among schoolchildren in Greece: a cross-sectional study and review of the literature

OBJECTIVE

To examine the prevalence and determinants of obesity and associated cardiovascular risk factors in a sample of Greek children.

METHODS

This is a cross-sectional, school-based study of 780 students (9.2 +/- 1.8 years old, 415 boys) conducted in Eastern Attica, the greater area of the city of Athens. The study protocol included anthropometric, blood pressure (BP), and biochemical measurements, as well as dietary and lifestyle habits assessment. A review of Greek studies on childhood obesity was also performed.

RESULTS

Approximately 22% of the participants were overweight and 8% were obese, which is in accordance with the results of 24 previous Greek studies showing the childhood overweight/obesity prevalence in the range of 30%. Overweight/obese children compared with normal-weight children had higher BP, lower high-density lipoprotein cholesterol (HDL-C), and higher triglycerides (p < 0.05 for all). Parental weight, consumption of sweets and fast-food, and decreased physical activity were independent determinants of being overweight/obese. Furthermore, overweight/obesity predicted the presence of high BP, low HDL-C, and high triglycerides.

CONCLUSION

A close association was revealed between obesity and metabolic abnormalities, underlining the need for early screening and intervention in overweight children in order to address the emerging childhood obesity epidemic in Greece.

Effect of regular physical activity on carotid intima-media thickness. Results from a 6-year prospective study in the early stage of hypertension

AIM

To study the effect of leisure-time physical activity on the progression of carotid intima-media thickness (IMT) in the early stage of hypertension.

METHODS

We studied 47 sedentary and 40 physically active young pre-hypertensive or stage 1 hypertensive subjects. IMT was assessed in the common carotid artery, carotid bulb and internal carotid artery at baseline and after 6.5 years.

RESULTS

Cumulative maximum IMT of the three carotid segments (M-MAX, 0.13 ± 0.08 vs 0.10 ± 0.07 mm, p = 0.006) and cumulative mean IMT (m-IMT, 0.11 ± 0.07 vs 0.09 ± 0.06 mm, p = 0.01), adjusted for confounders, increased to a greater degree in the sedentary than the active subjects. Differences in known risk factors explained a large proportion of the observed association. Inclusion of baseline cholesterol in the regression model attenuated the strength of the association for both M-MAX (p = 0.04) and m-IMT (p = 0.049). When also baseline blood pressure, heart rate, and body mass index were taken into account the association with physical activity status remained significant for maximum IMT of internal carotid artery (p = 0.034) and was of borderline significance for M-MAX (p = 0.066).

CONCLUSIONS

Physical activity can delay the progression of carotid IMT in hypertension. This effect is mediated in substantial part by the better risk factor profile in active subjects.

Pediatric hypertension update

PURPOSE OF REVIEW

The field of childhood hypertension has been changing rapidly since publication of the most recent consensus guidelines contained in the 2004 'Fourth Report'.

RECENT FINDINGS

Several epidemiologic studies have indicated that the prevalence of hypertension in children and adolescents is on the increase. A major factor behind this increase is the childhood obesity epidemic. There is substantial new information on the frequency of hypertensive target-organ damage in the young, including vascular, cardiac and renal effects. These data have led some authorities to recommend changes in how hypertension is evaluated and managed in the young.

SUMMARY

There has been significant new knowledge gained about many aspects of childhood hypertension over the past 5 years. Clinicians who care for children and adolescents with high blood pressure should familiarize themselves with these new data and incorporate them into their clinical decision-making.

Body mass index, cardiovascular risk factors, and carotid intima-media thickness in a pediatric population in southern Italy

OBJECTIVES

Obesity and exposure to cardiovascular risk factors during adolescence may be associated with the development of atherosclerosis and cardiovascular diseases later in life. The objective of the study was to investigate whether any excess body weight, including moderate overweight, is associated with a more severe cardiovascular risk profile and signs of early atherosclerosis in a pediatric population.

PATIENTS AND METHODS

A cross-sectional study was conducted among 646 adolescents ages 11 to 13 years from several primary schools of Reggio Calabria, Italy. Body mass index, waist circumference, blood pressure, glucose, insulin, homeostatic model assessment of insulin resistance, total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, triglycerides, and C-reactive protein (CRP) were determined. All of the subjects underwent carotid ultrasonography for the measurement of intima-media thickness. Complete clinical data were available from 575 subjects.

RESULTS

Overweight was similarly frequent in boys and girls (31.2% vs 31.0%), whereas prevalence of obesity was higher in boys (18.4% vs 10.1%). Subjects with lower levels of HDL and higher levels of triglycerides, insulin, and CRP plasma were observed more frequently among overweight and obese subjects than nonoverweight. At multivariate analysis, HDL cholesterol, insulin, and CRP were associated (P < 0.05) with overweight and obesity in girls, whereas in boys, insulin and CRP were associated (P < 0.05) with overweight and obesity, and LDL cholesterol with obesity. The association between overweight or obesity and increased intima-media thickness, a sign of early atherosclerosis, was present in girls (P < 0.05) and was close to statistical significance in obese boys (P = 0.07).

CONCLUSIONS

Overweight and obese adolescents have a higher prevalence of cardiovascular risk factors and show signs of early atherosclerosis. In girls, in particular, overweight is sufficient to determine a more severe cardiovascular risk profile.

High blood pressure in children: clinical and health policy implications

Hypertension is a global problem, affecting both developed and developing nations. In addition to being a major cause of morbidity and mortality, hypertension places a heavy burden on health care systems, families, and society as a whole. Despite evidence of an increasing prevalence of hypertension among youth, the consequences of early onset are poorly established and often overlooked. Childhood hypertension is often asymptomatic and easily missed, even by health professionals. Target organ damage is detectable in children and adolescents, however, and hypertension continues into adulthood. Additional strategies to improve cardiovascular health among children and adolescents are needed, including methods to achieve healthy lifestyles at home and in school, improved systems for diagnosis, and research on mechanisms and timing of interventions. The burden of hypertension in the young will continue to grow unless it is given the attention it deserves by policy makers, health care providers, schools, parents, and society. This report aims to increase awareness of the problem of hypertension in childhood. Recent reports on prevalence and target organ injury are discussed and health policy initiatives to improve blood pressure control are proposed.

Stress and inflammation: a biobehavioral approach for nursing research

Despite known advantages, the use of biobehavioral approaches in nursing research remains limited. The purposes of this article are to (1) present applications of stress and inflammation in various health conditions as examples of biobehavioral concepts and (2) stimulate similar applications of biobehavioral concepts in future nursing research. Under a biobehavioral conceptual framework, studies on stress and selective inflammatory biomarkers in cardiovascular, cancer, and pulmonary health are reviewed and summarized. Inflammation underlies many diseases, and stress is a significant source of increased inflammation. Biobehavioral concepts of stress and inflammation are highly relevant to nursing research concerned with health-related issues. Diverse biobehavioral concepts are readily applicable and should be utilized in nursing research with children and adults. To stimulate further biobehavioral research, more training and resources for nurse scientists, more unified conceptual definitions and biobehavioral conceptual frameworks, rigorous and expanded methodologies, and more collaboration are essential.

Hypertension, prehypertension, and transient elevated blood pressure in children: association with weight excess and waist circumference

BACKGROUND

To assess the prevalence of hypertension (H), prehypertension (PH), and transient elevated blood pressure (TH) and their relationship with weight class and waist circumference (WC) in an unselected population of Northern Italian children.

METHODS

A cross-sectional study was conducted in 5,131 children (5-11 years). Weight class was defined according to the International Obesity Task Force references, H and PH according to the National High Blood Pressure Education Program. A child was classified as having PH or H when systolic blood pressure (SBP) and/or diastolic blood pressure (DBP) at first screening were > or =90th percentile and the mean of three subsequent measures was between the 90th and 95th or > or =95th percentile, respectively. When BP values at the first screening were > or =90th percentile but the mean of three subsequent measures was <90th percentile the child was classified as having TH.

RESULTS

A proportion of 3.4% presented H, 2.7% PH, and 10.4% TH, 20% overweight, and 6% obesity. Weight class and WC were significantly associated to an increased risk of falling into any of the hypertensive categories. In children with TH BP z-scores of the mean of the three subsequent measurements following the first screening were significantly higher than BP z-scores observed in normotensive children (P value <0.001).

CONCLUSIONS

Weight class and WC are associated with BP. This is observed not only for H but also for PH, and for nonsustained forms of H. Prospective studies are needed to assess whether children with PH and TH will develop sustained H.

Hypertension in children: new trends and challenges

Childhood HTN (hypertension) has become a widely investigated topic within the last decade due to its increasing prevalence. In the present review, we examine new developments and trends that have significantly contributed to aetiology, diagnosis, evaluation and management of childhood HTN. Many recent reports document an increasing prevalence of HTN, mainly essential HTN, in children worldwide. This is probably related to the increase of childhood obesity, although obesity is not the only factor. Evidence has been accumulating to suggest a rather complex interplay between obesity, uric acid level, dietary sodium intake, inflammation, inheritance and other factors, which lead to increased risk of developing HTN in childhood and adulthood. The detection and monitoring of HTN has significantly improved with the use of ABPM (ambulatory blood pressure monitoring), which allows not only for a more accurate classification and staging of HTN, but also for the calculation of more sophisticated parameters such as the AASI (ambulatory arterial stiffness index). Measurement of arterial stiffness enables assessment of arterial dysfunction, which may precede structural vascular changes evaluated by carotid intima media thickness. Sustained HTN eventually leads to end-organ damage [LVH (left ventricular hypertrophy), central nervous system], which in turn increases the risk of cardiovascular morbidity and mortality. New developments in childhood HTN, as outlined in the present review, will hopefully contribute to better screening and management of HTN in children.

Adiposity predicts carotid intima-media thickness in healthy children and adolescents

OBJECTIVE

To examine whether anthropometric measurements, blood pressure (BP), fasting total cholesterol, and low-density lipoprotein are related to ultrasound measures of carotid intima-media thickness (CIMT) in children and teenagers with no known risk factors for cardiovascular disease.

STUDY DESIGN

This cross-sectional study included 599 subjects, 6 to 20 years of age (292 males, 307 females; 224 Hispanics, 210 European-Americans, 126 African-Americans, and 39 Asian-Americans) whose body mass index, waist circumference, BP, lipid profiles, and values for CIMT were determined.

RESULTS

Measures of CIMT were significantly greater in males than females (P=.006) and in African-Americans when compared with other ethnic groups (all P < .05). There were no relations between age, diastolic BP, or fasting levels of triglycerides, total cholesterol, or low-density lipoprotein values and CIMT measures, regardless of sex or ethnic background. Stratified multiple regression analysis indicated that body mass index and waist circumference independently predicted CIMT in both males and females, even after controlling for age, weight, BP, fasting lipid levels, and ethnic background.

CONCLUSION

Increased body mass and adiposity are associated with increased intima-media thickness in children and teenagers. This association is present in children not considered overweight, underscoring the need for the continued promotion of adequate nutritional and physical exercise behavior during childhood.

Hypertension after pediatric cardiac transplantation: detection, etiology, implications and management

While it may rescue children with end-stage heart failure from impending catastrophe, cardiac transplantation leaves 50-70% of pediatric recipients with new-onset hypertension. Given the unique vulnerability of the heart and kidneys in these children, we can expect long-term uncontrolled hypertension to shorten both graft and patient survival. In this review we discuss the multi-factorial etiology of post-transplant hypertension, highlighting current uncertainties and emphasizing mechanisms specific to cardiac recipients. We consider the optimal means of monitoring BP and in particular, the advantages of 24 h-ABP over intermittent clinic measurements. We also review BP treatment after cardiac transplantation, drawing attention to specific cautions appropriate when prescribing antihypertensive agents in these circumstances.

Blood pressure in children and target-organ damage later in life

The aim of this study was to examine the association between blood pressure (BP) in children and adolescents and cardiovascular and renal disease in adulthood. This was a retrospective study on patients <18 years of age with an elective admission to Landspitali University Hospital in Reykjavik, Iceland, between 1950 and 1967. We recorded baseline variables including BP and invited all patients for a follow-up visit in 2008 for repeat studies. We used chi(2), Fisher's exact test, and logistic regression to examine the association between BP in childhood and outcome variables at follow-up. We identified 126 individuals (54 men) for the study. The median age (range) at childhood admission was 15 (10-17) years and the median BP was 125/80 mmHg. Median age at follow-up was 58 (42-68) years, follow-up time 43 (25-52) years, and median BP 133/75 mmHg. Eleven had died (five men) and 49 had been diagnosed with hypertension (23 men) and 12 with coronary artery disease (ten men). There was a significant correlation between the diagnosis of coronary artery disease at follow-up and childhood systolic BP (odds ratio = 1.052; P = 0.03) as well as systolic BP >/= 95th percentile (P = 0.03). Our results suggest that elevated childhood systolic BP may increase the risk of coronary artery disease in adult life. The sample size is a limiting factor, and the study should be carried out in a larger population.

Subclinical atherosclerosis and related risk factors in renal transplant recipients

Long-term survival after successful renal transplantation is shortened by cardiovascular disease. Cardiovascular disease is a main cause of morbidity and death among children and young adults after renal transplantation. The aim of our study was to measure the carotid intima media thickness (cIMT) and determine its relationship to the risk factors for early arteriopathy in renal transplant recipients. Sixty-six stable renal transplant patients (36 female and 30 male), 7-25 years of age (mean 18.3 +/- 4.5 years) were enrolled in this study. The cIMT was measured by high-resolution B mode ultrasonography in multiple projections. The results were correlated with clinical and paraclinical parameters, including age, gender, body mass index (BMI), blood pressure, glomerular filtration rate (GFR), duration of dialysis, duration of chronic kidney disease (CKD), post-transplantation interval, calcium-phosphate (CaxP) product, cumulative dose of Ca-based P binder and calcitriol, lipid profile, uric acid, and cyclosporine level. The mean post-transplantation follow-up period was 64 +/- 40 months. The mean cIMT standard deviation score (SDS) of the patients and the control group was 0.60 +/- 0.81 mm (range -1.10 mm to 2.75 mm) and -1.25 +/- 0.95 mm (range -3.23 mm to 0.26 mm), respectively. Renal transplant recipients had a significantly greater cIMT than that of the controls (P < 0.001). Among several risk factors, there were positive correlations between cIMT SDS and gender, and cumulative dose of calcitriol (P = 0.02 and P = 0.02, respectively). In conclusion, subclinical atherosclerosis is present in young transplant recipients. Non-invasive monitoring of cIMT in renal transplant patients for the detection of early vascular lesions might be of value in preventing cardiovascular disease. Further studies are needed to see if proper monitoring of vitamin D therapy before and after transplantation could be helpful in the prevention of arteriopathy in renal transplant recipients.

Assessment and management of hypertension in children and adolescents

The epidemic of overweight and obesity in youth is increasing the prevalence of prehypertension and hypertension among children and adolescents. The younger the child is at presentation and the more severe the blood pressure abnormality, the more likely a secondary cause of hypertension is to be present. Measurement of blood pressure in children requires adaptation to the age and size of the child. Interpretation must be related to normative values specific for age, sex, and height. Evaluation is primarily aimed at identifying secondary causes of hypertension, associated comorbidities, additional risk factors, and evidence of target-organ damage. Ambulatory blood pressure monitoring is emerging as a useful tool for evaluation of some patients, particularly for those with suspected 'white coat' hypertension. Management of prehypertension and hypertension is directed at the underlying cause, exacerbating factors, and the magnitude of the blood pressure abnormality. Healthy behavioral changes are a primary management tool for treating hypertension and, more particularly, prehypertension and for addressing other cardiovascular risk factors, such as obesity. Pharmacological management is reserved for patients with hypertension who do not respond to behavioral changes, have additional cardiovascular risk factors or diabetes, are symptomatic, or have developed target-organ damage.

Regression of target organ damage in children and adolescents with primary hypertension

We assessed the effects of 12 months of non-pharmacological and pharmacological therapy on 24-h ambulatory blood pressure, regression of target organ damage (TOD) and metabolic abnormalities in 86 children (14.1 ± 2.4 years) with primary hypertension. Twenty-four hour systolic and diastolic blood pressure (BP) decreased (130 ± 8 vs 126 ± 8, 73 ± 7 vs 70 ± 7, p = 0.0001 and 0.004 respectively). Body mass index (BMI) did not change, but waist-to-hip (0.85 ± 0.07 vs 0.83 ± 0.05, p = 0.01) and waist-to-height ratio (WHtR; 0.49 ± 0.07 vs 0.48 ± 0.05, p = 0.008) decreased. Left ventricular mass index (LVMi; 38.5 ± 10.7 vs 35.2 ± 7.5 g/m(2.7), p = 0.0001), prevalence of left ventricular hypertrophy (46.5% vs 31.4%; p = 0.0001), carotid intima-media thickness (cIMT; 0.44 ± 0.05 vs 0.42 ± 0.04 mm, p = 0.0001), wall cross sectional area (WCSA; 7.5 ± 1.3 vs 6.9 ± 1.2 mm(2), p = 0.002), hsCRP (1.1 ± 1.0 vs 0.7 ± 0.7 mg/l, p = 0.002), and LDL-cholesterol (115 ± 33 vs 107 ± 26 mg/dl, p = 0.001) decreased. Patients who had lowered BP had a lower cIMT at the second examination (0.41 ± 0.04 vs 0.43 ± 0.04 mm, p = 0.04) and lower initial hsCRP values (0.9 ± 0.7 vs 1.5 ± 1.3 mg/l, p = 0.04) in comparison to non-responders. Regression analysis revealed that the main predictor of LVMi decrease was a decrease in abdominal fat expressed as a decrease in waist circumference (WC) (R (2) = 0.280, β = 0.558, p = 0.005), for WCSA-SDS a decrease in WC (R (2) = 0.332, β = 0.611, p = 0.009) and for a cIMT-SDS decrease the main predictor was a decrease in hsCRP concentrations (R (2) = 0.137, β = 0.412, p = 0.03). Standard antihypertensive treatment lowered BP and led to regression of TOD in hypertensive children. Lean body mass increase and decrease in abdominal obesity correlated with TOD regression.

Vascular health in children and adolescents: effects of obesity and diabetes

The foundations for cardiovascular disease in adults are laid in childhood and accelerated by the presence of comorbid conditions, such as obesity, diabetes, hypertension, and dyslipidemia. Early detection of vascular dysfunction is an important clinical objective to identify those at risk for subsequent cardiovascular morbidity and events, and to initiate behavioral and medical interventions to reduce risk. Typically, cardiovascular screening is recommended for young adults, especially in people with a family history of cardiovascular conditions. Children and adolescents were once considered to be at low risk, but with the growing health concerns related to sedentary lifestyle, poor diet and obesity, cardiovascular screening may be needed earlier so that interventions to improve cardiovascular health can be initiated. This review describes comorbid conditions that increase cardiovascular risk in youth, namely obesity and diabetes, and describes noninvasive methods to objectively detect vascular disease and quantify vascular function and structure through measurements of endothelial function, arterial compliance, and intima-media thickness. Additionally, current strategies directed toward prevention of vascular disease in these populations, including exercise, dietary interventions and pharmacological therapy are described.

Synergistic effects of elevated systolic blood pressure and hypercholesterolemia on carotid intima-media thickness in children and adolescents

This study aimed to investigate the synergistic effects of elevated systolic blood pressure (SBP) and hypercholesterolemia on carotid intima-media thickness (cIMT). For this study, 60 children with hypercholesterolemia and 40 healthy control children were divided into four subgroups: hypercholesterolemic children with normal (<90th percentile) or elevated (>or= 90th percentile) SBP and control children with normal or elevated SBP. The highest mean and maximal cIMT values were found in the hypercholesterolemic children with elevated SBP and were significantly different from those of all the other groups. The synergistic effects of elevated SBP and hypercholesterolemia lead to a significant increase in cIMT as a subclinical sign of early atherosclerosis.

Noninvasive assessment of subclinical atherosclerosis in children and adolescents: recommendations for standard assessment for clinical research: a scientific statement from the American Heart Association

Deterioration in endothelial function and arterial stiffness are early events in the development of cardiovascular diseases. In adults, noninvasive measures of atherosclerosis have become established as valid and reliable tools for refining cardiovascular risk to target individuals who need early intervention. With limited pediatric data, the use of these techniques in children and adolescents largely has been reserved for research purposes. Therefore, this scientific statement was written to (1) review the current literature on the noninvasive assessment of atherosclerosis in children and adolescents, (2) make recommendations for the standardization of these tools for research, and (3) stimulate further research with a goal of developing valid and reliable techniques with normative data for noninvasive clinical evaluation of atherosclerosis in pediatric patients. Precise and reliable noninvasive tests for atherosclerosis in youth will improve our ability to estimate future risk for heart attack and stroke. Currently, large longitudinal studies of cardiovascular risk factors in youth, such as the Bogalusa and Muscatine studies, lack sufficient adult subjects experiencing hard outcomes, such as heart attack and stroke, to produce meaningful risk scores like those developed from Framingham data.

Relation of blood pressure and body mass index during childhood to cardiovascular risk factor levels in young adults

INTRODUCTION

Adult obesity and hypertension are leading causes of cardiovascular morbidity/mortality. Although childhood BMI and blood pressure (BP) track into adulthood, how they influence adult cardiovascular risk independent of each other is not well defined.

METHODS

Participants were from two longitudinal studies with a baseline evaluation at mean age of 13 years and a follow-up at mean age of 24 years. Regression models using childhood BP and BMI to predict young adult cardiovascular risk factors were performed.

RESULTS

In univariate analysis, childhood BMI predicted young adult BP, lipids, glucose, insulin and insulin resistance, whereas childhood BP predicted young adult BP, lipids and glucose. In a multivariable regression model (adjusted for age, sex and race), which included change in BMI and BP from age 13 to 24 years, BMI predicted all young adult risk factors except BP and glucose. Baseline SBP predicted young adult BP, cholesterol, triglycerides and glucose whereas baseline DBP predicted young adult BP, BMI and glucose.

CONCLUSION

The results from this study show that BP and BMI act independently in children to influence future cardiovascular risk factors and the combination of high BP and BMI in childhood has an additive effect in predicting the highest levels of young adult cardiovascular risk. Thus, there should be a focus on treating hypertension in overweight and obese children, in addition to attempting to reduce weight.

Concepts guiding therapy for hypertension in children

Increasing attention has been focused on identifying children with prehypertension and hypertension (HTN). Obesity and low birthweight are two risk factors that predispose children to develop HTN during their childhood years or later as adults. Early onset of pre-HTN and HTN increases the lifetime risk for cardiovascular sequelae. Lifestyle modification should be part of the initial recommendations for management of all hypertensive children. In those children requiring pharmacologic therapy, the choice of medication should be guided by the etiology of HTN, the needs of the child and the risk and benefit profiles of the various drug classes. The long-term impact of antihypertensive therapy in children is not known. Concerns regarding the effects of HTN and its treatment on cognitive function are of particular importance in the growing child and warrant further study. Ongoing investigations that offer promise for innovative therapeutic approaches in the future are discussed.

Current advances in chronic kidney disease in children: growth, cardiovascular, and neurocognitive risk factors

Linear growth and neurocognitive development are two of the most important differences between adults and children, in terms of clinical issues that must be addressed in patients with chronic kidney disease (CKD). Correction of metabolic acidosis, nutritional deficiency, and renal osteodystrophy improve linear growth, but many children require administration of growth hormone to achieve normal growth. A variety of neurocognitive deficits occur in children with CKD, although there has been an improvement in outcome via improved dialysis, correction of malnutrition, and decreased aluminum exposure. Although growth and neurocognitive development are delayed, cardiovascular complications are accelerated in children with CKD, and are reflected in a dramatic increase in cardiovascular mortality compared with healthy children. Other early cardiovascular complications in children with CKD include left ventricular hypertrophy, cardiac dysfunction, and vascular calcifications.

Relation of carotid intima-media thickness and aortic valve sclerosis (from the ISMIR study ["Ispessimento Medio Intimale e Rischio Cardiovascolare"] of the Italian Society of Cardiovascular Echography)

Carotid intima-media thickness (IMT) and aortic valve sclerosis (AVS) have recently emerged as important predictive factors for cardiovascular (CV) events. However, few data are available on their association and the respective roles of major CV risk factors in determining either condition. In this study, 479 asymptomatic subjects (mean age 58 +/- 13 years, 62% men) were assessed, without histories of CV disease, consecutively referred for comprehensive evaluations by echocardiography and carotid ultrasonography because of the presence of > or = 1 risk factor. Common carotid artery IMT and aortic valve morphology and function were analyzed. The mean IMT was 0.82 +/- 0.19 mm. The prevalence of increased carotid IMT (>0.80 mm) and AVS was 60.8% and 18.4%, respectively. The prevalence of increased IMT was 79.6% in subjects with AVS and 56.5% in those without AVS (relative risk 2.99, 95% confidence interval 1.72 to 5.21, p <0.001). On multivariate analysis, increased IMT was significantly and independently associated with hypertension, dyslipidemia, obesity, family history of CV disease, and age. Only age emerged as an independent predictor of AVS. The presence of both markers was independently associated only with hypertension and age. In conclusion, increased carotid IMT was strongly associated with AVS in a population of asymptomatic patients. IMT and AVS were differently related to individual CV risk factors, and their association seems to be correlated mainly with age and hypertension.

Association between blood pressure and carotid intima-media thickness

OBJECTIVE

To investigate the association between blood pressure and carotid intima-media thickness (IMT) in healthy adolescents.

STUDY DESIGN

Study participants included 285 first-year high school students (mean age, 15.2 years) at a rural high school in Korea. Systolic and diastolic blood pressure (SBP and DBP) were measured with an oscillometric automated sphygmomanometer. The carotid arteries were evaluated with high-resolution B-mode ultrasound scanning. IMT value was determined with the average of the maximal IMT at each common carotid artery. Increased IMT was defined as sex-specific top quartile. The odds ratio (OR) for increased IMT per 1 SD increase of SBP and DBP was estimated after adjusting for age, sex, body mass index, waist circumference, fasting glucose level, and total/high-density lipoprotein cholesterol ratio.

RESULTS

Adjusted OR for increased IMT was 1.70 (P = .003) per 12.4 mm Hg SBP and 1.25 (P = .125) per 7.0 mm Hg DBP. When the analyses were performed by sex, increased IMT was associated with both SBP (OR, 2.67; P = .003) and DBP (OR, 1.68; P = .019) in girls, but it was not associated with either SBP (OR, 1.46; P = .093) or DBP (OR, 0.99; P = .972) in boys.

CONCLUSION

These results suggest that higher blood pressure level may be associated with increased carotid IMT in apparently healthy adolescents.

Intima-media thickness measurements in children with cardiovascular risk factors

Measuring intima-media thickness (IMT) is now a standard diagnostic procedure in assessing cardiovascular risk and hypertensive target-organ damage (TOD) in adults. There is also an increasing number of pediatric publications evaluating IMT in children from high-risk groups, such as those with arterial hypertension, diabetes, chronic kidney disease, obesity, dyslipidemia, and homocystinurias. It has been shown that carotid IMT is strongly related with other markers of TOD in children with arterial hypertension and with metabolic cardiovascular risk factors. In children with coarctation of the aorta, carotid IMT correlated both with blood pressure and even with mild residual aortic gradient. On the other hand, studies in children with high cardiovascular risk have shown that normalization of blood pressure and metabolic abnormalities led to regression of arterial changes and decrease of IMT. Although not yet accepted as standard pediatric procedure, IMT measurement is emerging as a promising method of assessing TOD and cardiovascular risk and monitoring treatment efficacy. From a practical point of view, clinical utility of IMT measurements seems to be similar to use of echocardiography in assessing left ventricular mass. However, IMT measurements in children and adolescents should be standardized to avoid bias caused by the use of different measurement methods.

Efficacy, safety, and pharmacokinetics of candesartan cilexetil in hypertensive children aged 6 to 17 years

This 4-week randomized, double blind, placebo-controlled study (N=240), 1-year open label trial (N=233), and single-dose pharmacokinetic study (N=22) evaluated candesartan cilexetil (3 doses) in hypertensive children aged 6 to 17 years. Seventy-one percent were 12 years of age or older, 71% were male, and 47% were black. Systolic (SBP)/diastolic (DBP) blood pressure declined 8.6/4.8-11.2/8.0 mm Hg with candesartan and 3.7/1.8 mm Hg with placebo (P<.01 compared to placebo for SBP and for the mid and high doses for DBP; placebo-corrected 4.9/3.0-7.5/6.2 mm Hg). The slopes for dose were not, however, different from zero (P>.05). The response rate (SBP and DBP <95th percentile) after 1 year was 53%. The pharmacokinetic profiles in 6- to 12- and 12- to 17-year-olds were similar and were comparable to adults. Eight candesartan patients discontinued treatment because of an adverse event. Candesartan is an effective, well-tolerated antihypertensive agent for children aged 6 to 17 years and has a pharmacokinetic profile that is similar to that in adults.

Evaluation and treatment of hypertension in general pediatric practice

Hypertension (HTN) in children and adolescents has become increasingly common. We sought to identify variability in the approach to HTN among general pediatricians as well as obstacles to care of hypertensive youth by surveying pediatricians referring to an urban children's hospital. Although most pediatricians begin blood pressure measurement at 3 years, there was substantial variability in the initial diagnostic evaluation of hypertensive patients. Just 7% of pediatricians routinely start antihypertensive drug treatment for HTN, whereas 82% refer their hypertensive patients to a specialist; 40% of pediatricians felt uncomfortable evaluating and treating HTN. Pediatricians unfamiliar with The Fourth Report were more likely to be uncomfortable with the care of hypertensive patients than those familiar with it (54% vs 33%, P < .05). Current practice does not appear to follow recent consensus recommendations. Interventions designed to address the issues identified in this survey may lead to improved care for pediatric patients with HTN.

The influence of adolescent body mass index, physical activity, and tobacco use on blood pressure and cholesterol in young adulthood

PURPOSE

To test the independent influences of adolescent tobacco use, physical activity/inactivity, and body mass index (BMI) on young adult cardiovascular risk factors.

METHODS

This is a prospective cohort study using data from Waves I and III of the National Longitudinal Study of Adolescent Health (Add Health) (N = 14,322). We tested whether Wave I tobacco use, physical activity/inactivity, and BMI predicted self-report of being diagnosed with high blood pressure (BP) or high cholesterol by Wave III, while controlling for gender, age, race/ethnicity, use of healthcare, and Wave III tobacco use, physical activity/inactivity, BMI.

RESULTS

Among young adults aged 18-26, 5.37% report high BP and 4.28% high cholesterol. Obese adolescents are more likely to report high BP by young adulthood than normal-weight adolescents, independent of all control variables including BMI in young adulthood (adjusted odds ratio [aOR] = 1.96; 95% confidence interval = [1.50-2.57]). Overweight and obese adolescents are more likely to report high cholesterol by young adulthood than normal-weight adolescents, independent of all control variables including BMI in young adulthood (aOR = 1.47 [1.14-1.90] and 2.05 [1.44-2.91], respectively). Adolescent tobacco use and physical activity/inactivity do not independently predict reported high BP or cholesterol.

CONCLUSIONS

The odds of overweight and obese adolescents reporting a diagnosis for two cardiovascular risk factors by young adulthood are 1.5 to two times higher than normal-weight adolescents, regardless of BMI in young adulthood. The impact of transient and sustained increases in adolescent BMI on the evolution of cardiovascular risk warrants further investigation.

Elevated blood pressure, race/ethnicity, and C-reactive protein levels in children and adolescents

OBJECTIVE

Adult hypertension is independently associated with elevated C-reactive protein levels, after controlling for obesity and other cardiovascular risk factors. The objective of this study was to determine, with a nationally representative sample of children, whether the relationship between elevated blood pressure and C-reactive protein levels may be evident before adulthood.

METHODS

Cross-sectional data for children 8 to 17 years of age who participated in the National Health and Nutrition Examination Survey between 1999 and 2004 were analyzed. Bivariate analyses compared children with C-reactive protein levels of >3 mg/L versus <or=3 mg/L with respect to blood pressure and other cardiovascular risk factors. Multivariate linear regression was used to evaluate the relationship between elevated blood pressure and C-reactive protein levels.

RESULTS

Among 6112 children, 3% had systolic blood pressure of >or=95th percentile and 1.3% had diastolic blood pressure of >or=95th percentile. Children with C-reactive protein levels of >3 mg/L had higher systolic blood pressure, compared with children with C-reactive protein levels of <or=3 mg/L (109 vs 105 mm Hg). Obesity, high-density lipoprotein cholesterol levels of <40 mg/dL, and Hispanic ethnicity were independent predictors of elevated C-reactive protein levels. Diastolic blood pressure did not differ between groups. Linear regression analyses showed that systolic blood pressure of >or=95th percentile was independently associated with C-reactive protein levels in boys but not girls. Subset analyses according to race/ethnicity demonstrated that the independent association of elevated systolic blood pressure with C-reactive protein levels was largely limited to black boys.

CONCLUSIONS

These data indicate that there is interplay between race/ethnicity, elevated systolic blood pressure, obesity, and inflammation in children, a finding that has potential implications for disparities in cardiovascular disease later in life.

Ambulatory arterial stiffness index is increased in hypertensive childhood disease

Arterial hypertension in adults is often associated with an increased arterial stiffness, which correlates with the ambulatory arterial stiffness index (AASI) as derived from ambulatory blood pressure (BP) measurements. The purpose of this study was to demonstrate whether children with diagnosed hypertension have an increased AASI as in hypertensive adults. AASI was calculated from 185 ambulatory BP measurements of 114 hypertensive and 71 normotensive, healthy children. Hypertensive children had higher AASI values compared with their normotensive healthy counterparts (0.370 +/- 0.120 versus 0.204 +/- 0.199, p < 0.0001). Children with longer duration of hypertension or a history of primary or secondary aortic coarctation displayed even more elevated AASI values. A receiver operator curve derived cut-off of AASI set at 0.301 distinguished (p < 0.0001) hypertensive from normotensive children with an odds ratio of 8.2, a sensitivity of 81%, and a specificity of 65%. Moreover, AASI correlated with pulse and systolic BP. In conclusion, AASI is elevated in hypertensive children and correlates with the duration and the origin of hypertension in childhood.

Cardiovascular risk in 26,008 European overweight children as established by a multicenter database

OBJECTIVE

Although the obesity epidemic is progressing in European children too, there is no consensus on the population-specific prevalence of comorbidities or efficient diagnostic strategies. Therefore, weight-related risk factors, their interrelationship, and association with biological parameters were assessed in a large group of overweight (OW) children, documented by an electronic database.

METHODS AND PROCEDURES

Data of 26,008 children (age 12.6+/-2.9 years, 56% females) presented for OW (BMI >90th percentile) or obesity (>97th percentile) in 98 specialized centers were evaluated using a simple software (Adipositas Patienten Verlaufsbeobachtung (APV)) for standardized longitudinal documentation. After local anonymization, data were transmitted for central analysis including multiple logistic regression.

RESULTS

A total of 5.9% of the children were normal weight, 41% obese (OB), and 37% extremely OB (>99.5th percentile, XXL; 41% of the girls). In 50%, at least one risk factor and in 11% a cluster of two were found, comprising increased blood pressure (BP): 35.4%, dyslipidemia: 32% (total cholesterol: 14.1%, low-density lipoprotein (LDL)-cholesterol: 15.8%, high-density lipoprotein (HDL)-cholesterol: 11.1%, triglycerides: 14.3%), impaired glucose tolerance (IGtT): 6.5% and suspicion of diabetes: 0.7%. The degree of OW was inversely associated with HDL-cholesterol and directly with clustered risk factors, impaired glucose metabolism, increased BP and triglycerides (odds ratios (ORs) XXL vs. normal=6.15, >10, 4.3, 3.0 and 2.5, respectively), but not with LDL-cholesterol.

DISCUSSION

In a very large cohort of young Europeans risk factors for cardiovascular (CV) diseases are frequently found, related to the degree of OW and tend to cluster, thus a comprehensive screening is justified in all OW or OB children. Electronic patient documentation is feasible in a large obesity care network.

Children and adolescents with obesity-associated high blood pressure

Hypertension and obesity are both common health problems in children and adolescents. More than 17% of children are obese and even more children are overweight. Hypertension, although defined differently in children than in adults, can be detected in 3% to 4% of children, and approximately 30% of obese adolescents have high blood pressure (BP) associated with obesity. Children with high BP and obesity frequently have other risk factors that are components of the metabolic syndrome. Evidence of target organ damage, including left ventricular hypertrophy, is detectable in many children with hypertension and is more commonly found in children with high BP and obesity. Both obesity and hypertension are considered inflammatory conditions. There are some emerging data in the young that show an association of insulin resistance, obesity, and high BP with inflammatory markers. Children and adolescents with hypertension and especially obesity-associated hypertension can be identified and should be evaluated for additional metabolic risk factors. Considering the heightened risk for premature cardiovascular (CV) disease, therapeutic interventions, including lifestyle changes and medications, when indicated, are important for all children and adolescents with obesity-associated hypertension.

Pediatric hypertension: recent trends and accomplishments, future challenges

Publication of the Fourth Report on high blood pressure (BP) in children and adolescents by the National High BP Education Program (NHBPEP) in 2004 has been followed by a remarkable increase in interest in pediatric hypertension. New data have emerged on the epidemiology of hypertension in the young, the influence of the childhood obesity epidemic on BP, how ambulatory BP monitoring (ABPM) can be used in evaluating elevated BP and the extent of hypertensive target-organ damage in the pediatric age group. Exciting new information on drug treatment of pediatric hypertension has been produced by industry-sponsored clinical trials of antihypertensive medications spurred by the FDA Modernization Act (FDAMA) and successor legislation. Despite these trends, recognition of elevated BP in children and adolescents by primary care providers remains problematic. This article will highlight these and other aspects of pediatric hypertension, hopefully providing a snapshot of where we are in early 2008, and pointing out areas where further work is needed in order to reduce the future burden of adult cardiovascular disease.

Prospective analysis of carotid arterial wall structure in pediatric renal transplants with ambulatory normotension and in treated hypertensive recipients

Increased carotid IMT was found to be associated with cardiovascular risk factors. As pediatric renal transplants are at high risk for cardiovascular disease, we examined whether there is a relationship between BP and IMT in normotensive and in treated hypertensive recipients after transplantation. Thirty-one recipients aged 10 +/- 3.5 yr (16 M, 15 F) underwent repeated carotid ultrasound examinations 5.4 +/- 3.2 yr after transplantation with a 4.1 +/- 1 yr interval and were followed with annual ambulatory BP monitoring. Baseline IMT was significantly higher in transplants compared with controls. When recipients were again investigated, follow-up IMT measurements were similar compared with measurements obtained at baseline. The analysis of variance showed that baseline IMT both in recipients with strict normotension, i.e., ambulatory normotension without antihypertensive therapy at baseline and throughout the study period (n = 9), and in recipients with treated hypertension or newly diagnosed hypertension (n = 22) was significantly higher than in healthy controls (n = 21). Baseline IMT did not differ between these subgroups of recipients. Similarly, pairwise comparisons showed that baseline and follow-up IMT within each subgroup of recipients were not significantly different. Overall and regardless of time-point, no significant associations were found between systolic and diastolic 24-h BP, daytime BP, night-time BP, ambulatory BP standard deviation scores, BP loads and IMT. Our results suggest that increased IMT in pediatric renal transplants does not seem to be related to BP but more likely to other factor(s) not investigated in this study.