2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents

Albuminuric and non-albuminuric reduced eGFR phenotypes in youth with type 1 diabetes: Factors associated with cardiometabolic risk

BACKGROUND AND AIM

Albuminuria and reduced eGFR are hallmarks of Diabetic Kidney Disease in adults. Our aim was to analyze factors associated with albuminuric and non-albuminuric mildly reduced eGFR phenotypes in youths with type 1 diabetes.

METHODS AND RESULTS

This multicenter cross-sectional study included 1549 youths (age 5-17 years) with type 1 diabetes enrolled at 14 Italian Pediatric Diabetes Centers. Albuminuria, creatinine, glycosylated hemoglobin (HbA1c), lipids, blood pressure (BP), neutrophils (N) and lymphocytes (L) count were analyzed. Uric acid (UA) was available in 848 individuals. Estimated GFR (eGFR) was calculated using bedside Schwartz's equation. The sample was divided in three phenotypes: 1) normoalbuminuria and eGFR ≥90 mL/min/1.73 m² (reference category, n = 1204), 2) albuminuric and normal GFR phenotype (n = 106), 3) non-albuminuric mildly reduced GFR (MRGFR) phenotype (eGFR 60-89 mL/min/1.73 m², n = 239). Albuminuric and non-albuminuric reduced eGFR phenotypes were significantly associated with autoimmune thyroiditis (P =0.028 and P=0.044, respectively). Albuminuric phenotype showed high risk of high HbA1c (P=0.029), high BP (P < 0.001), and low HDL-C (P =0.045) vs reference category. Non-albuminuric MRGFR phenotype showed high risk of high BP (P < 0.0001), low HDL-C (P =0.042), high Triglycerides/HDL-C ratio (P =0.019), and high UA (P < 0.0001) vs reference category.

CONCLUSION

Non albuminuric MRGFR phenotype is more prevalent than albuminuric phenotype and shows a worst cardiometabolic risk (CMR) profile). Both phenotypes are associated with autoimmune thyroiditis. Our data suggest to evaluate both albuminuria and eGFR earlier in type 1 diabetes to timely identify young people with altered CMR profile.

Could arterial stiffness be early reversible target organ damage test in childhood hypertension?

OBJECTIVE

The recommended treatment for hypertension (HTN) in children has been revised recently. This study aimed to present the changes in target organ damage (TOD) and arterial stiffness parameters after treatment in children with primary HTN who were managed in accordance with the 2016 European Society of Hypertension Guidelines.

METHODS

Patients with primary HTN included in this study were newly diagnosed, untreated, and were followed-up for a minimum of 6 months. HTN was confirmed by 24-h ambulatory blood pressure monitoring (ABPM). All patients underwent the following assessments: anthropometrical measurements of body mass index (BMI), carotid intima-media thickness (cIMT), left ventricular mass index (LVMI), plasma creatinine, urea, electrolytes, uric acid, fasting plasma glucose, blood lipids, urinalysis, urine culture, and first morning urine albumin tocreatinine ratio. The ABPM device performed measurements such as central blood pressure (cBP) and pulse wave velocity (PWV).

RESULTS

Thirty-two of 104 patients were enrolled. Seventeen patients were male, and 53% were obese. Compared with pretreatment, creatinine, urea, systolic BP (SBP), diastolic BP (DBP), systolic load, diastolic load, central SBP (cSBP), cSBP z score, cDBP, and PWV z score decreased, whereas LVMI and BMI z scores were unchanged.

CONCLUSION

After BP improvement, while LVMI did not regress, the cSBP, cSBP z, and PWV z score values, which are markers of arterial stiffness, regressed. This supports the corrective effect of BP control on the cardiovascular system even in a short-term follow-up. Further longitudinal studies are needed for the assessment of BP control on arterial stiffness in childhood.

Isolated systolic hypertension in young males: a scoping review

Isolated systolic hypertension typically occurs in young males; however, its clinical significance is unknown. Given the prevalence of the hypertension and its contribution to global morbidity and mortality, a synthesis of the most recent available evidence around isolated systolic hypertension is warranted. This review aims firstly to review the haemodynamic and physical characteristics indicative of cardiovascular risk in young males (aged 18 to 30 years) with isolated systolic hypertension, and secondly to synthesize the associated clinical management recommendations reported in the literature. Six databases were systematically searched for all relevant peer-reviewed literature examining isolated systolic hypertension in young males. Search results were screened and examined for validity, those that did not meet the inclusion criteria were removed. A total of 20 articles were appropriate for inclusion. Key factors indicative of cardiovascular risk in isolated systolic hypertension were characterized by several distinctive haemodynamic parameters and physical characteristics. After the literature was synthesized based around these key factors, two distinct cohorts (healthy and unhealthy) were highlighted. The healthy cohort of younger males with isolated systolic hypertension was associated with a decreased cardiovascular risk and therefore no medical interventions were recommended. The second (unhealthy) cohort was, however, associated with an increased cardiovascular risk and may therefore, benefit from antihypertensive therapy.

Patient and caregiver perspectives on blood pressure in children with chronic kidney disease

BACKGROUND

Over 50% of children with chronic kidney disease (CKD) have uncontrolled hypertension, increasing their long-term risk of cardiovascular disease and progression to kidney failure. Children receiving medications or dialysis may also experience acute blood pressure fluctuations accompanied by debilitating symptoms. We aimed to describe the perspectives of children with CKD and their parental caregivers on blood pressure, to inform patient-centered care.

METHODS

Secondary thematic analysis was conducted on qualitative data from the Standardized Outcomes in Nephrology-Children and Adolescents initiative, encompassing 16 focus groups, an international Delphi survey, and two consensus workshops. We analyzed responses from children with CKD (aged 8-21 years) and caregivers (of children aged 0-21 years) pertaining to blood pressure.

RESULTS

Overall, 120 patients and 250 caregivers from 22 countries participated. We identified five themes: invisibility and normalization (reassured by apparent normotension, absence of symptoms, expected links with CKD); confused by ambiguity (hypertension indistinguishable from cardiovascular disease, questioning need for prophylactic intervention, frustrated by inconsistent messages, struggling with technical skills in measurement); enabling monitoring and maintaining health (gauging wellbeing, preventing vascular complications); debilitating and constraining daily living (provoking anxiety and agitation, helpless and powerless, limiting life activities); and burden of medications (overwhelmed by quantity of tablets, distress from unexpected side effects).

CONCLUSIONS

For children with CKD and their caregivers, blood pressure was an important heath indicator, but uncertainty around its implications and treatment hampered management. Providing educational resources to track blood pressure, and minimizing symptoms and treatment burden, may improve outcomes in children with CKD.

Atrial and Ventricular Structural and Functional Alterations in Obese Children

Background and objectives: Childhood obesity has reached epidemic levels in the world. Obesity in children is defined as a body mass index (BMI) equal to or above the 95th percentile for age and sex. The aim of this study was to determine early changes in cardiac structure and function in obese children by comparing them with their nonobese peers, using echocardiography methods. Materials and methods: The study enrolled 35 obese and 37 age-matched nonobese children. Standardized 2-dimensional (2D), pulsed wave tissue Doppler, and 2D speckle tracking echocardiography were performed. The z-score BMI and lipid metabolism were assessed in all children. Results: Obese children (aged 13.51 ± 2.15 years; 20 boys; BMI z-score of 0.88 ± 0.63) were characterized by enlarged ventricular and atrial volumes, a thicker left ventricular posterior wall, and increased left ventricular mass. Decreased LV and RV systolic and diastolic function was found in obese children. Atrial peak negative (contraction) strain (−2.05% ± 2.17% vs. −4.87% ± 2.97%, p < 0.001), LV and RV global longitudinal strain (−13.3% ± 2.88% vs. −16.87% ± 3.39%; −12.51% ± 10.09% vs. −21.51% ± 7.42%, p < 0.001), and LV global circumferential strain (−17.0 ± 2.7% vs. −19.5 ± 2.9%, p < 0.001) were reduced in obese children. LV torsion (17.94° ± 2.07° vs. 12.45° ± 3.94°, p < 0.001) and normalized torsion (2.49 ± 0.4°/cm vs. 1.86 ± 0.61°/cm, p = 0.001) were greater in obese than nonobese children. A significant inverse correlation was found between LV and RV global longitudinal strain and BMI (r = −0.526, p < 0.01; r = −0.434, p < 0.01) and total cholesterol (r = −0.417, p < 0.01). Multivariate analysis revealed that the BMI z-score was independently related to LV and RV global longitudinal strain as well as LV circumferential and radial strain. Conclusion: 2D speckle tracking echocardiography is beneficial in the early detection of regional LV systolic and diastolic dysfunctions, with preserved ejection fraction as well as additional RV and atrial involvement, in obese children. Obesity may negatively influence atrial and ventricular function, as measured by 2D speckle tracking echocardiography. Obese children, though they are apparently healthy, may have subclinical myocardial dysfunction.

Mean Arterial Pressure and Chronic Kidney Disease Progression in the CKiD Cohort

[Figure: see text].

Achieved clinic blood pressure level and chronic kidney disease progression in children: a report from the Chronic Kidney Disease in Children cohort

BACKGROUND

Control of hypertension delays progression of pediatric chronic kidney disease (CKD), yet few data are available regarding what clinic blood pressure (BP) levels may slow progression.

METHODS

Longitudinal BP data from children in the Chronic Kidney Disease in Children cohort study who had hypertension or an auscultatory BP ≥ 90th percentile were studied. BP categories were defined as the maximum systolic or diastolic BP percentile (< 50th, 50th to 75th, 75th to 90th, and ≥ 90th percentile) with time-updated classifications corresponding to annual study visits. The primary outcome was time to kidney replacement therapy or a 30% decline in estimated glomerular filtration rate. Cox proportional hazard models described the effect of each BP category compared to BP ≥ 90th percentile.

RESULTS

Seven hundred fifty-four participants (median age 9.9 years at study entry) met inclusion criteria; 65% were male and 26% had glomerular CKD. Any BP < 90th percentile was associated with a decreased risk of progression for those with glomerular CKD (hazard ratio (HR), 0.63; 95% CI, 0.28-1.39 (< 50th); HR, 0.59; 95% CI, 0.28-1.26 (50th-75th); HR, 0.40; 95% CI, 0.18-0.93 (75th-90th)). Similar results were found for those with non-glomerular CKD: any BP < 90th percentile was associated with decreased risk of progression (HR, 0.78; 90% CI, 0.49-1.25 (< 50th); HR, 0.53; 95% CI, 0.33-0.84 (50th-75th); HR, 0.71; 95% CI, 0.46-1.08 (75th-90th)).

CONCLUSIONS

Achieved clinic BP < 90th percentile was associated with slower CKD progression in children with glomerular or non-glomerular CKD. These data provide guidance for management of children with CKD in the office setting. Graphical abstract.

Impact of the 2017 American Academy of Pediatrics' Clinical Practice Guideline on the Identification and Risk Stratification of Youth at Increased Cardiovascular Disease Risk

The updated clinical practice guideline (CPG) published by the American Academy of Pediatrics in 2017 introduced significant changes to the diagnostic and evaluative approach towards children with elevated blood pressure. The goals of this review were to summarize the current evidence regarding the impact of the new CPG on the identification and risk stratification of children at increased cardiovascular disease risk. Universally, the new CPG definitions of abnormal blood pressure led to more children classified as having a hypertensive blood pressure when compared with alternative definitions. Youth who moved to a higher blood pressure stage with the CPG typically had worse cardiometabolic profiles and more comorbidites. The association of CPG-defined hypertension and concurrent intermediate cardiovascular disease outcomes such as left ventricular hypertrophy and increased pulse wave velocity remains unclear; however, longitudinal data suggests an improved identification of those at greatest risk for adult cardiovascular disease with the CPG definitions. The majority of studies reviewed used blood pressure from one encounter, not replicate blood pressures from multiple visits, to define an abnormal or hypertensive blood pressure. Therefore, future studies investigating the prevalence of confirmed hypertension and the association between confirmed hypertension and outcomes are needed to optimally characterize the performance of the new CPG on identifying children at cardiovascular disease risk.

Scientific mapping of the research output on hypertension in children and adolescents, 2010-2018

OBJECTIVE

The area of pediatric hypertension (HTN) research has seen substantial progress over the last two decades, but no bibliometric analysis has yet been undertaken to describe these advances. This study aims to describe the published research examining HTN in children and adolescents from 2000 to 2018.

METHODS

Articles were retrieved using PubMed and the Web of Science. Analyses were performed to quantify the evolution of scientific output, identifying the leading journals, authors, and countries as well as the existing collaboration networks. Likewise, we identified the most cited articles, describing their document type, main topic focus, and the age of the patients studied.

RESULTS

In total, we identified 8317 articles in the Web of Science. The annual number of publications doubled over the study period. Articles were published in 1415 journals, mainly in the categories of Peripheral & Vascular Diseases and Pediatrics. The USA dominated scientific production in the field. Regarding researcher productivity, the top 202 authors participated in 20% of the articles, and there were 47 stable research clusters, with the largest component made up of 17 authors. Altogether, there were 145 most cited articles, with an irregular annual distribution; about half focus on HTN itself, while the rest study associated disorders and conditions.

CONCLUSION

This is the first study to analyze scientific output on HTN in children and adolescents. The snapshot that emerges is of a research area that is growing but is still in a relatively early phase of development.

Isolated nocturnal hypertension is associated with increased left ventricular mass index in children

BACKGROUND

Isolated nocturnal hypertension (INH) is associated with increased prevalence of left ventricular hypertrophy (LVH) and cardiovascular morbidity and mortality in adult patients. Unlike in adults, data illustrating the possible association between INH and cardiac target organ damage is lacking in children. This study aimed to investigate whether INH is associated with increased left ventricular mass index (LVMI) and LVH in children.

METHODS

Retrospective data from all untreated children with confirmed ambulatory hypertension (HT) in our center was reviewed. Ambulatory blood pressure monitoring (ABPM) and echocardiography were performed concurrently. Ambulatory normotensive children served as controls. LVH was defined as LVMI ≥ 95th percentile.

RESULTS

There were 102 ABPM studies; of these, 79 children had renal HT, and 23 had primary HT. Median age of children was 13.2 years (3.8-18.9). Nineteen children had INH, 9 children had isolated daytime HT, 54 had daytime and nighttime HT, and 20 were normotensive. The LVMI adjusted for age (patient's LVMI/95th percentile of the LVMI) was significantly higher in children with INH than in normotensive children (0.83 ± 0.03 vs. 0.74 ± 0.03, p = 0.03). Left ventricular hypertrophy was present in 11% of children with INH; this was not significantly higher than in normotensive children (0%, p = 0.23).

CONCLUSIONS

This study investigated the association between INH and cardiac structure in children with primary and renal HT and showed children with INH had higher LVMI adjusted for age than normotensive children and children with INH had similar LVMI adjusted for age to children with isolated daytime HT.

Serum Periostin as a Potential Biomarker in Pediatric Patients with Primary Hypertension

Experimental studies suggest that periostin is involved in tissue repair and remodeling. The study aimed to evaluate serum periostin concentration as potential biomarker in pediatric patients with primary hypertension (PH). We measured serum periostin, blood pressure, arterial damage, biochemical, and clinical data in 50 children with PH and 20 age-matched healthy controls. In univariate analysis, children with PH had significantly lower serum periostin compared to healthy peers (35.42 ± 10.43 vs. 42.16 ± 12.82 [ng/mL], p = 0.038). In the entire group of 70 children serum periostin concentration correlated negatively with peripheral, central, and ambulatory blood pressure, as well as with aortic pulse wave velocity (aPWV). In multivariate analysis, periostin level significantly correlated with age (β = -0.614, [95% confidence interval (CI), -0.831--0.398]), uric acid (β = 0.328, [95%CI, 0.124-0.533]), body mass index (BMI) Z-score (β = -0.293, [95%CI, -0.492--0.095]), high-density lipoprotein (HDL)-cholesterol (β = 0.235, [95%CI, 0.054-0.416]), and triglycerides (β = -0.198, [95%CI, -0.394--0.002]). Neither the presence of hypertension nor blood pressure and aPWV influenced periostin level. To conclude, the role of serum periostin as a biomarker of elevated blood pressure and arterial damage in pediatric patients with primary hypertension is yet to be unmasked. Age, body mass index, uric acid, and lipid concentrations are key factors influencing periostin level in pediatric patients.

Risk of hypertension into adulthood in persons born prematurely: a national cohort study

AIMS

Preterm birth has been associated with elevated blood pressure early in life; however, hypertension risks from childhood into adulthood remain unclear. We conducted a large population-based study to examine gestational age at birth in relation to hypertension risks from childhood into adulthood.

METHODS AND RESULTS

A national cohort study was conducted of all 4 193 069 singleton live births in Sweden during 1973-2014, who were followed up for hypertension identified from nationwide inpatient and outpatient (specialty and primary care) diagnoses from any health care encounters through 2015 (maximum age 43 years; median 22.5). Cox regression was used to examine gestational age at birth in relation to hypertension risk while adjusting for other perinatal and maternal factors, and co-sibling analyses assessed the potential influence of unmeasured shared familial (genetic and/or environmental) factors. In 86.8 million person-years of follow-up, 62 424 (1.5%) persons were identified with hypertension (median age 29.8 years at diagnosis). Adjusted hazard ratios for new-onset hypertension at ages 18-29 years associated with preterm (<37 weeks) and extremely preterm (22-27 weeks) birth were 1.28 [95% confidence interval (CI), 1.21-1.36] and 2.45 (1.82-3.31), respectively, and at ages 30-43 years were 1.25 (1.18-1.31) and 1.68 (1.12-2.53), respectively, compared with full-term birth (39-41 weeks). These associations affected males and females similarly and appeared substantially related to shared genetic or environmental factors in families.

CONCLUSIONS

In this large national cohort, preterm birth was associated with increased risk of hypertension into early adulthood. Persons born prematurely may need early preventive evaluation and long-term monitoring for the development of hypertension.

Pediatric and Adult Ambulatory Blood Pressure Thresholds and Blood Pressure Load as Predictors of Left Ventricular Hypertrophy in Adolescents

[Figure: see text].

Stability study of a compounded oral solution of nicardipine for the treatment of hypertension in children

Nicardipine is an antihypertensive drug that may be used off-label by oral route to treat hypertension in children. Currently commercially available tablets are inappropriate for oral use in children and manufactured hard capsules are not suitable for easy dose individualization to achieve target blood pressure. We aimed to fulfill this lack of appropriate dose forms by developing an oral liquid formulation of nicardipine. We compounded an extemporaneous 2 mg/mL nicardipine solution in InOrpha® vehicle for oral use with 1% polysorbate 80. A HPLC-MS/MS stability-indicating method was developed and validated. The stability was assessed under room temperature and refrigerated storage conditions. Nicardipine concentration remained above 95% of the initial concentration for 90 days in both storage conditions, without apparition of degradation products. Organoleptic parameters, pH, osmolality, viscosity and density were assessed and remained stable throughout storage. A uniformity of content was maintained before and after agitation of the packaging bottles. Mass uniformity of delivered doses was also ensured. Finally, the formulation met the Pharmacopoeia specifications for microbiological contaminations. In this study we report a compounded formulation of nicardipine for oral use in pediatrics. This solution, which could be easily manufactured, is being used in our hospital. Pharmacological and clinical parameters including bioavailability, pharmacokinetics, efficacy and tolerance remain to be assessed.

Racial differences of early vascular aging in children and adolescents

The prevalence of non-communicable disease (NCDs) is rising globally, with a large burden recorded in sub-Saharan countries and populations of black race/ethnicity. Accelerated vascular deterioration, otherwise known as early vascular aging (EVA), is the underlying factor for highly prevalent NCDs such as hypertension. The etiology of EVA is multifactorial with a central component being arterial stiffness with subsequent development of hypertension and cardiovascular complications. Although arterial stiffness develops with increasing age, many children and adolescents are subjected to the premature development of arterial stiffness, due to genetic or epigenetic predispositions, lifestyle and behavioral risk factors, and early life programming. Race/ethnic differences in pediatric populations have also been reported with higher aortic stiffness in black (African American) compared with age-matched white (European American) counterparts independent of blood pressure, body mass index, or socioeconomic status. With known evidence of race/ethnic differences in EVA, the pathophysiological mechanisms underlying graded differences in the programming of EVA are still sparse and rarely explored. This educational review aims to address the early life determinants of EVA in children and adolescents with a particular focus on racial or ethnic differences.

Early vascular aging in adult patients with congenital heart disease

Many studies have reported that adults with congenital heart disease suffer from hypertension and cardiovascular disease even at younger ages. Therefore, we analyzed early vascular aging, which is defined as pulse wave velocity values higher than the 95th percentile for age and sex, and clarified the relationship between early vascular aging and many parameters related to cardiovascular disorders in adults with congenital heart disease. We enrolled 72 adult patients with congenital heart disease and measured their brachial-ankle pulse wave velocity. Comparing the data between age- and sex-matched controls, patients with a pulse wave velocity higher than the 95th percentile for age and sex were defined as exhibiting early vascular aging. The parameters of patients with and without early vascular aging were compared. Early vascular aging was observed in 15.6% of the patients. Age, systolic blood pressure, diastolic blood pressure, pulse pressure, blood sugar, hemoglobin A1c, uric acid, low-density lipoprotein cholesterol, and triglyceride levels were positive determinants of early vascular aging. Logistic regression analysis proved that systolic blood pressure was a significant determinant of early vascular aging (odds ratio, 1.128, 95% confidence interval, 1.049-1.214; p = 0.001). The prevalence of early vascular aging is high in adult patients with congenital heart disease. Because early vascular aging can damage a patient's vulnerable heart, careful follow-up of blood pressure and pulse wave velocity is essential.

Blood pressure and resting heart rate in 3-17-year-olds in Germany in 2003-2006 and 2014-2017

To track blood pressure (BP) and resting heart rate (RHR) in children and adolescents is important due to its associations with cardiovascular outcomes in the adulthood. Therefore, the aim of this study was to examine BP and RHR over a decade among children and adolescents living in Germany using national examination data. Cross-sectional data from 3- to 17-year-old national survey participants (KiGGS 2003–06, n = 14,701; KiGGS 2014–17, n = 3509) including standardized oscillometric BP and RHR were used for age- and sex-standardized analysis. Measurement protocols were identical with the exception of the cuff selection rule, which was accounted for in the analyses. Different BP and RHR trends were observed according to age-groups. In 3- to 6-year-olds adjusted mean SBP and DBP were significantly higher in 2014–2017 compared to 2003–2006 (+2.4 and +1.9 mm Hg, respectively), while RHR was statistically significantly lower by −3.8 bpm. No significant changes in BP or in RHR were observed in 7- to 10-year-olds over time. In 11- to 13-year-olds as well as in 14- to 17-year-olds lower BP has been observed (SBP −2.4 and −3.2 mm Hg, respectively, and DBP −1.8 and −1.7 mm Hg), while RHR was significantly higher (+2.7 and +3.7 bpm). BP trends did not parallel RHR trends. The downward BP trend in adolescents seemed to follow decreasing adult BP trends in middle and high-income countries. The increase in BP in younger children needs confirmation from other studies as well as further investigation. In school-aged children and adolescents, the increased RHR trend may indicate decreased physical fitness.

Nighttime Home Blood Pressure in Children: Association with Ambulatory Blood Pressure and Preclinical Organ Damage

[Figure: see text].

Within-visit SBP variability from childhood to adulthood and markers of cardiovascular end-organ damage in mid-life

BACKGROUND

Within-visit SBP variability is associated with age and SBP, but its long-term clinical significance is unknown. We examined the association between child, adult, and life-time within-visit SBP variability with markers of end-organ damage using data from a 31-year longitudinal study.

METHODS

Within-visit SBP variability was calculated as the standard deviation of three sitting SBP readings among up to 3010 participants aged 6-18 years (childhood) who were re-measured up to seven times to mid-adulthood. Markers of cardiovascular end-organ damage in adulthood were carotid intima--media thickness, brachial flow-mediated dilatation, carotid distensibility, pulse wave velocity, left ventricular mass index, carotid plaque, and coronary artery calcification.

RESULTS

The mean (standard deviation) cumulative within-visit SBP variability was 2.7 (1.5) mmHg in childhood, 3.9 (1.9) mmHg in adulthood and 3.7 (1.5) mmHg across the observed life-time. Childhood within-visit SBP variability was not correlated with its subsequent values measured from 3 to 31 years later. With adjustment for age, sex, cumulative SBP, BMI and serum lipids, neither child, adult, or life-time cumulative within-visit SBP variability associated with markers of cardiovascular end-organ damage. However, higher child, adult, and life-time cumulative SBP significantly associated with higher carotid intima--media thickness, higher pulse wave velocity, lower brachial flow-mediated dilatation, lower carotid distensibility in adulthood.

CONCLUSION

Within-visit SBP variability from childhood to adulthood does not provide additional predictive utility over SBP over the same period of the life course.

LONG TERM RENAL SURVIVAL OF PEDIATRIC PATIENTS WITH LUPUS NEPHRITIS

BACKGROUND

Childhood-onset systemic lupus erythematosus (SLE) is more severe than adult-onset disease, including more frequent kidney involvement. This study aimed to investigate baseline clinical features, treatment modalities, short- and long-term renal outcomes of pediatric patients with lupus nephritis (LN).

MATERIALS AND METHODS

This study enrolled 53 LN patients out of 102 childhood-onset SLE patients followed at Hacettepe University between 2000-2020. The demographic and clinical data were reviewed retrospectively from the medical charts and electronic records. All SLE patients with renal involvement underwent renal biopsy either at the time of diagnosis or during follow-up.

RESULTS

The median age at onset of SLE was 13.3 (IQR : 10.4-15.8) years. The median follow-up duration was 43.1 (IQR : 24.3-69.3) months. Of the 102 SLE patients, 53 patients (52%) had lupus nephritis (LN). The most frequent histopathological class was class IV LN (54.7%), followed by class III LN (22.6%). The proportion of patients who achieved either complete or partial remission were 77.3% and 73% at 6 and 12 months, respectively. In the overall LN cohort, 5- and 10-year renal survival rates were 92% and 85.7%, respectively. The remission rate at 6th month was significantly higher in Mycophenolate mofetil (MMF) and Cyclophosphamide (CYC) treated groups than other combination therapies (p = 0.02). Although no difference was found between the CYC and MMF response rates (p = 0.57), in the proliferative LN (Class III and IV), the vast majority of class IV patients (%79) received CYC as induction threapy. There was no difference between the response rates in any treatment regimens at 12th month (p = 0.56). In the multivariate analysis; male gender, requiring dialysis at the time of LN diagnosis, failure to achieve remission at 6th and at 12 th months were found to be associated with poor renal outcome.

CONCLUSION

Our study demonstrated that male gender, failure to achieve remission at 6th and at 12 th months, and requiring dialysis at the time of diagnosis were the best predictors of poor renal outcome. Therefore, appropriate and agressive management of pediatric LN is essential to achieve and maintain remisson.

Bone Disease in CKD in Children

This manuscript discusses mineral and bone disorders of chronic kidney disease (MBD-CKD) in pediatric patients with special emphasis on the underlying pathophysiology, the causes and clinical profile of growth retardation, the alterations in the growth plate, the strategies to optimize growth and the medical recommendations for prevention and treatment.

Early ventricular contraction in children with primary hypertension relates to left ventricular mass

AIMS

In hypertensive adults, first-phase ejection fraction (EF1), a measure of early ventricular contraction is reduced and associated with prolonged systolic contraction and diastolic dysfunction. Whether this is true in children with primary hypertension is unknown.

METHODS

Echocardiography was performed in 47 normotensive and 81 hypertensive children. Hypertensive children were stratified according to tertiles of LVMi (g/m2.7). EF1 was calculated from the fraction of LV volume ejected up to the time of peak aortic flow. E/e' was used as a measure of diastolic function. Myocardial wall stress (MWS) was calculated in a subsample of children from LV volumes and central aortic pressure. Time to onset of relaxation (TOR) was defined as time to peak MWS over ejection time.

RESULTS

Normotensive and hypertensive children were of similar age. Hypertensive children in tertiles 2 and 3 of LVMi had higher BMI z-score than normotensives. EF1 was significantly increased in hypertensive children in tertile 1 compared with normotensive children (P < 0.001), whereas in those in tertile 3, it was significantly lower than in normotensive children (P < 0.001). EF1 was negatively associated with LVMi (β = -0.505, P < 0.001), LVM (β = -0.531, P = 0.001) and E/e' ratio (β = -0.409, P < 0.001); in children who had MWS measured, TOR was negatively associated with EF1 (β = -0.303, P = 0.007) and positively associated with E/e' (β = 0.459, P < 0.001).

CONCLUSION

EF1 is preserved or enhanced in hypertensive children with similar LVMi to normotensive children but is increasingly reduced in those with greater LVMi. This reduction of EF1 is associated with prolonged myocardial wall stress and reduced diastolic function.

Hypertension and childhood stroke

Cerebrovascular disease (stroke) is one of the ten leading causes of death in children and adolescents. Multiple etiologies, from arteriopathies to prothrombic states, can cause stroke in youth. In adult stroke, hypertension has been shown to be the single most important modifiable risk factor. Although hypertension has not been strongly identified as a risk factor in childhood stroke to date, there is preliminary evidence that suggests that hypertension may also be associated with stroke in children. In this review, we summarize the literature that may link hypertension to stroke in the young. We have identified a series of barriers and limitations in the fields of pediatric hypertension and pediatric neurology that might explain why hypertension has been overlooked in childhood stroke. We suggest that hypertension may be a relevant risk factor that, alone or in combination with other multiple factors, contributes to the development of stroke in children. Currently, there are no consensus guidelines for the management of post-stroke hypertension in children. Thus, we recommend that blood pressure be assessed carefully in every child presenting with acute stroke in order to better understand the effects of hypertension in the development and the outcome of childhood stroke. We suggest a treatment algorithm to help practitioners manage hypertension after a stroke.

Prognostic value of ambulatory blood pressure and clinical use of echocardiography to detect left ventricular hypertrophy in children evaluated for primary hypertension

BACKGROUND

Hypertension (HTN) is common in children and often associated with pathologic progression to end organ damage, specifically left ventricular hypertrophy (LVH).

METHODS

The primary goal of this retrospective chart review is to determine if patients with higher blood pressure were more likely to complete echocardiogram (ECHO) and more likely to have LVH, among a pediatric population referred for hypertension evaluation before the 2017 American Academy of Pediatrics (AAP) guidelines. To meet this goal, the number of patients evaluated by ECHO and prevalence of LVH was examined for independent associations with blood pressure and BMI categories by logistic regression.

RESULTS

It was found that higher blood pressure was associated with having an ECHO evaluation (p = 0.012). Among patients evaluated by ECHO, one-third had LVH but the presence of LVH was not associated with blood pressure severity or use of anti-hypertensive medication. Instead, BMI was the only factor associated with LVH cardiac remodeling in our population (p = 0.025).

CONCLUSIONS

Newly updated AAP practice guidelines recommend evaluation of HTN via ABPM, with ECHO performed only at the initiation of pharmaceutical therapy. It is notable that BMI, the only risk factor of LVH found in this study, is not addressed in the current AAP guidelines for ECHO evaluation among hypertensive children. This study suggests that ECHO evaluation may be warranted in a larger subset of children as is recommended by current European Society of Hypertension pediatric guidelines.

Regulatory T-cell subset distribution in children with primary hypertension is associated with hypertension severity and hypertensive target organ damage

BACKGROUND

The relationship between circulating regulatory T-cell (Tregs) subset distribution and hypertension severity in children with primary hypertension is not known. We aimed to find out if target organ damage (TOD) in children with primary hypertension is related to defects in Tregs distribution reflected by their phenotype characteristics.

METHODS

The study constituted 33 nontreated hypertensive children and 35 sex-matched and age-matched controls. Using multicolor flow cytometry technique, we assessed a distribution of the total Tregs (CD4CD25CD127) and their subsets (CD45RA-naive Tregs, CD45RA memory/activated Tregs, CD45RACD31 recent thymic emigrants Tregs and mature naive CD45RACD31 Tregs) in the whole blood.

RESULTS

Hypertensive children showed decreased percentage of the total Tregs, the CD45RA-naive Tregs, the total CD31 Tregs and the recent thymic emigrants Tregs but elevation of the CD45RA memory/activated Treg and mature naive CD45RACD31 Tregs. Decreased frequency of the total Tregs, naive Tregs and CD31-bearing Treg cell subsets (CD31 total Tregs, CD45RACD31 recent thymic emigrants Tregs) negatively correlated to TOD markers, arterial stiffness and blood pressure elevation. In contrast, increased percentage of memory Tregs and CD31 Tregs subsets positively correlated to organ damage markers, arterial stiffness and blood pressure values. These changes were independent of BMI, age, sex and hsCRP.

CONCLUSION

Both diagnosis of hypertension, TOD and arterial stiffness in hypertensive children were associated with decreased population of total CD4 Tregs, limited output of recent thymic emigrants Tregs, and increased pool of activated/memory Tregs. Hypertension was an independent predictor of the circulating Treg subsets distribution irrespective of hsCRP.

Uric Acid Associates With Executive Function in Children and Adolescents With Hypertension

[Figure: see text].

Diagnosis of Pediatric Hypertension: European Society of Hypertension-Recommended 24-Hour vs. 24-Hour-Day-Night Ambulatory Blood Pressure Thresholds

BACKGROUND

The impact of diagnosing pediatric hypertension based on all three-24-hour, day and night ambulatory blood pressure (ABP) thresholds (combined ABP threshold) vs. conventionally used 24-hour ABP threshold is not known.

METHODS

In this cross-sectional, retrospective study from a tertiary care outpatient clinic, we evaluated the diagnosis of hypertension based on the 24-hour European Society of Hypertension (ESH) and combined ESH ABP thresholds in untreated children with essential hypertension. The American Academy of Pediatrics (AAP) and Fourth Report thresholds were used to classify office blood pressure (OBP).

RESULTS

In 159 children, aged 5-18 years, the 24-hour ESH and combined ESH thresholds classified 82% (95th confidence interval (CI) 0.68, 0.97) ABP similarly with the area under the curve (AUC) of 0.86 (95th CI 0.80, 0.91). However, the AUC of the 2 ABP thresholds was significantly higher in the participants with office hypertension than office normotension, with OBP classified by the AAP (AUC 0.93, 95th CI 0.84, 0.98 vs. 0.80, 95th CI 0.71, 0.88) or Fourth Report (AUC 0.93, 95th CI 0.83, 0.98 vs. 0.81, 95th CI 0.73, 0.88) threshold. With OBP classified by the either OBP threshold, the combined ESH threshold diagnosed significantly more masked hypertension (MH) (difference 15%, 95th CI 4.9, 24.7; P = 0.00); however, the diagnosis of white coat hypertension (WCH) by the 2 ABP thresholds did not differ significantly (difference 4%, 95th CI 1.8, 10; P = 0.16).

CONCLUSIONS

In children with essential hypertension, the 24-hour and combined ESH thresholds have a stronger agreement for diagnosing WCH than MH.

European Network for blood pressure research in children and adolescents (COST Action CA 19115)

High blood pressure is a clearly established modifiable risk factor for cardiovascular and renal disease. Although most of its adverse effects develop in adulthood, it has become clear that high BP is a lifelong problem that can manifest early in life. While few would dispute the importance of taking effective steps to identify and manage this condition in middle-aged and elderly individuals, relatively little attention has been paid to the problem of high BP in children and adolescents. Therefore, the development of actions focused on early childhood, childhood and adolescence and the investigation of the underlying causes of this epidemic are of utmost importance. There is a pressing need for comprehensive pan-European action to increase the knowledge on the prevention, diagnosis and treatment of high blood pressure in children and adolescents, the current scarcity of which impedes the development of consensus across different research fields and hinders efforts to introduce changes in clinical practice. There are some aspects that demand urgent action: the definition of hypertension, the prevalence of high BP in Europe, accurate measurement for early identification, the assessment of hypertension-mediated organ damage and the development and implementation of prevention strategies. In order to provide answers to all of these unanswered questions and challenges, a multidisciplinary network was established, maintained and funded by the European Cooperation in Science and Technology (COST) Association. COST is a funding organization for the creation of research networks known as COST Actions. In this case, the network will promote coordinated and collaborative activities on personalized preventive measures for children and adolescents across Europe.

Should ACE inhibitors or calcium channel blockers be used for post-transplant hypertension?

Arterial hypertension in renal transplant recipients warrants antihypertensive treatment. The preferable choice of antihypertensives that should be used in patients after kidney transplantation remains a matter of debate; however, calcium channel blockers (CCB) and angiotensin-converting enzyme inhibitors (ACEI) are currently the most commonly used antihypertensives. This educational review summarizes the current evidence about the effects of these two classes of medications in transplant recipients. Several studies have demonstrated that both classes of drugs can reduce blood pressure (BP) to similar extents. Meta-analyses of adult randomized controlled trials have shown that graft survival is improved in patients treated with ACEIs and CCBs, and that CCBs increase, yet ACEIs decrease, graft function. Proteinuria is usually decreased by ACEIs but remains unchanged with CCBs. In children, no randomized controlled study has ever been performed to compare BP or graft survival between CCBs and ACEIs. Post-transplant proteinuria could be reduced in children along with BP by ACEIs. The results of the most current meta-analyses recommend that due to their positive effects on graft function and survival, along with their lack of negative effects on serum potassium, CCBs could be the preferred first-line antihypertensive agent in renal transplant recipients. However, antihypertensive therapy should be individually tailored based on other factors, such as time after transplantation, presence of proteinuria/albuminuria, or hyperkalemia. Furthermore, due to the difficulty in controlling hypertension, combination therapy containing both CCBs and ACEIs could be a reasonable first-step therapy in treating children with severe post-transplantation hypertension.

Retrospective analysis of clinical and pathomorphological features of lupus nephritis in children

PURPOSE

The aim of the study was to evaluate the clinical course and pathomorphological correlations in Polish children with the diagnosis of lupus nephritis (LN).

METHODS

We retrospectively analyzed the medical records of 39 children hospitalized due to LN in 7 pediatric nephrology units in Poland between 2010 and 2019. Demographic data, clinical symptoms at the onset of LN and laboratory parameters were reviewed. We analyzed Systemic Lupus Erythematosus Disease Activity Index (SLEDAI), histological LN findings with the activity (IA) and chronicity index (IC).

RESULTS

We examined 32 girls and 7 boys, median age at LN onset was 14.75 (IQR 13.0-16.0) years, SLEDAI of 22.0 (IQR 18.0-27.0) points; LN histological class: IV (59.4%), III (18.9%), III/V (10.8%), IV/V (8.1%), VI (2.7%); IA 8.0 (IQR 6.0-11.0) points, IC 1.05 (IQR 0-2.0) points. Children with nephrotic (n ​= ​22) and non-nephrotic (n ​= ​17) proteinuria differed in median Hb level (9.55, IQR 8.3-11.2 vs 10.9, IQR 10.1-11.6 ​g/L; P ​< ​0.05), albumin level (2.5, IQR 2.1-3.19 vs 3.6, IQR 3.4-4.1 ​g/dL; P ​< ​0.001), proteinuria (5.76, IQR 3.0-7.5 vs 1.08, IQR 0.53-1.50 ​g/day; P ​< ​0.0001), eGFR (53.9, IQR 27.0-68.8 vs 96.7, IQR 73.8-106.2 ​mL/min/1.73 ​m²; P ​< ​0.01) and occurrence of hypertension (77% vs 23%; P ​< ​0.01). In multivariate analysis Hb level (β ​= ​8.0; 95%CI, 1.90-14.11) was the significant predictor of eGFR<90 ​mL/min/1.73 ​m².

CONCLUSIONS

Proliferative forms of LN in children may have a varying clinical presentation. Children with LN with nephrotic range proteinuria have lower Hb level, lower eGFR and higher occurrence of hypertension. Hb level is the significant predictor of eGFR<90 ​mL/min/1.73 ​m² in children with LN.

Magnitude and significance of interarm blood pressure differences in children and adolescents

BACKGROUND

An interarm difference (IAD) in blood pressure (BP) of 10 mmHg or more is a potential cardiovascular risk factor in adults, given its association with cardiovascular events/mortality. In children and adolescents, accurate BP assessment is critical for identifying risk of end organ damage. However, IAD has not been systematically studied in paediatric patients; if present and of significant magnitude, measuring BP in only one arm could lead to misclassification of hypertensive status.

METHOD

In 95 children/adolescents with a normal aorta (including 15 with a history of tetralogy of Fallot) aged 7-18 years attending the Royal Children's Hospital, Melbourne, we aimed to determine the magnitude of IAD, frequency of IAD of at least 10 mmHg, difference in BP classification between arms, and influence of repeat measures on IAD in a single visit. After 5 min rest, simultaneous bilateral BP was measured in triplicate with an automated device.

RESULTS

Absolute systolic IAD was 5.0 mmHg (median, interquartile range 2-8 mmHg) and was 10 mmHg or more in 14%, with no change on repeat measures. In patients with a history of aortic surgery, IAD of 10 mmHg or more occurred in 27% (transposition of the great arteries, n = 15) and 75% (aortic coarctation, n = 8). Differences in BP classification, based on initial left vs. right arm measures, occurred in 25% (normal aorta) and 40%/63% (aortic surgery), or 17% and 33%/50%, respectively if second and third measurements were averaged.

CONCLUSION

Substantial interarm BP differences were common, even in apparently healthy children and adolescents: evaluation of IAD may, therefore, be important for BP classification in the paediatric setting.

Vascular diameter and intima-media thickness to diameter ratio values of the carotid artery in 642 healthy children

In children, arterial alterations occur with increased intima-media thickness as well as vascular diameter enlargement. Both conditions correlate with higher cardiovascular risk in adults, and both the array and proportion of these alterations are important hemodynamic parameters. In terms of functional adaptation processes, they influence several arterial wall properties as for example the shear and tensile stress of the vessel. There are no reference values for the vascular diameter and intima-media thickness/diameter ratio of the carotid artery in children. Therefore, this study aimed to assess vascular diameter, intima-media thickness/diameter ratio and related tensile stress values in children and to further investigate the influence of sex, age, body mass index, and blood pressure. The parameters were measured with high-resolution semi-automated ultrasound. Sex- and age-dependent values were calculated with the LMS method for a cross-sectional sample of 642 healthy, non-obese children aged 8-17 years. The mean vascular diameter was 5.45 ± 0.46 mm; the median intima-media thickness/diameter ratio was 0.085 (0.079-0.092); the median tensile stress was 105.4 (95.2-116.4) kPa. The vascular diameter and the tensile stress were higher, and the intima-media thickness/diameter ratio was lower in boys than in girls. In comparison to the normal weight study population the excludedobese children had a significantly higher diameter, a lower intima-media thickness/diameter ratio, and a higher tensile stress. In multiple regression analyses of diameter, intima-media thickness/diameter ratio, and tensile stress, all parameters were influenced by sex and body mass index. Furthermore, systolic and diastolic blood pressure significantly influenced the vascular diameter, and systolic blood pressure significantly influenced the intima-media thickness/diameter ratio. Conclusion: This study is the first to report values for the diameter, the intima-media thickness/diameter ratio of the carotid artery, and the related tensile stress allowing a more differentiated view of cardiovascular adaptations as it combines structural and functional vascular parameters. What is known: • Intima-media thickness and vascular diameter are related to a higher cardiovascular risk in adults • The intima-media thickness/diameter ratio gives information about hemodynamic and functional vessel adaptation What is new: • Values for vascular diameter, intima-media thickness/diameter ratio, and tensile stress of the carotid artery in children are presented in this study • Intima-media thickness as a surrogate marker for arterial health in children should be complemented by intima-media thickness/diameter ratio measurement.

A reappraisal of the prevalence of pediatric hypertension through a nationwide database in Taiwan

Hypertension in childhood and adolescence is associated with adult cardiovascular morbidity and mortality. However, the reported prevalence of pediatric hypertension varies considerably. We conducted a pioneer nationwide population-based study to investigate the prevalence of hypertension among children and adolescents. Pediatric patients who had been diagnosed with hypertension between 2000 and 2013 were selected from the National Health Insurance Research Database in Taiwan. Other metabolic syndrome-related diseases that would increase cardiovascular risk, including diabetes mellitus (DM), hyperlipidemia, and obesity, were also retrieved for further evaluation. In total, 10,364 children and adolescents diagnosed with hypertension were identified. The prevalence of pediatric hypertension in Taiwan ranged from 0.19 to 0.38 per 1000 children and adolescents between 2000 and 2013. Essential hypertension was most commonly coded (90.6%), which was much more than secondary hypertension (14.3%). Children and adolescents with hypertension were often associated with DM, hyperlipidemia, and obesity, with the odds ratios as 14.05 (95% confidence interval (CI) 11.74-16.81, p < 0.001), 10.65 (95% CI 9.48-11.97, p < 0.001), and 19.08 (95% CI 15.65-23.26, p < 0.001), respectively. To improve lifelong cardiovascular health, our results emphasize the importance of early proper recognition and suitable management of hypertension, as well as metabolic syndrome-related diseases, among children and adolescents.

Association Between Central-Peripheral Blood Pressure Amplification and Structural and Functional Cardiac Properties in Children, Adolescents, and Adults: Impact of the Amplification Parameter, Recording System and Calibration Scheme

INTRODUCTION

Systolic blood pressure (SBPA) and pulse pressure amplification (PPA) were quantified using different methodological and calibration approaches to analyze (1) the association and agreement between different SBPA and PPA parameters and (2) the association between these SBPA and PPA parameters and left ventricle (LV) and atrium (LA) structural and functional characteristics.

METHODS

In 269 healthy subjects, LV and LA parameters were echocardiography-derived. SBPA and PPA parameters were quantified using: (1) different equations (n = 9), (2) methodological approaches (n = 3): brachial sub-diastolic (Mobil-O-Graph®) and supra-systolic oscillometry (Arteriograph®) and aortic diameter waveform re-calibration (RCD; ultrasonography), and (3) using three different calibration schemes: systo-diastolic (SD), calculated mean (CM) and oscillometric mean (OscM).

RESULTS

SBPA and PPA parameters obtained with different equations, techniques, and calibration schemes show a highly variable association level (negative, non-significant, and/or positive) among them. The association between SBPA and PPA with cardiac parameters were highly variable (negative, non-significant, or positive associations). Differences in BPA parameter data between approaches were more sensitive to the calibration method than to the device used. Both, SBPA and PPA obtained with brachial sub-diastolic technique and calibrated to CM or OscM showed higher levels of association with LV and LA structural characteristics.

CONCLUSIONS

Our data show that many of the parameters that assume to quantify the same phenomenon of BPA are not related to each other in the different age groups. Both, SBPA and PPA obtained with brachial sub-diastolic technique and calibrated to CM or OscM showed higher levels of association with LV and LA structural characteristics.

Changes in Body Size during Early Growth Are Independently Associated with Arterial Properties in Early Childhood

Nutritional status in early life stages has been associated with arterial parameters in childhood. However, it is still controversial whether changes in standardized body weight (z-BW), height (z-BH), BW for height (z-BWH) and/or body mass index (z-BMI) in the first three years of life are independently associated with variations in arterial structure, stiffness and hemodynamics in early childhood. In addition, it is unknown if the strength of the associations vary depending on the growth period, nutritional characteristics and/or arterial parameters analyzed. Aims: First, to compare the strength of association between body size changes (Δz-BW, Δz-BH, Δz-BWH, Δz-BMI) in different time intervals (growth periods: 0–6, 0–12, 0–24, 0–36, 12–24, 12–36, 24–36 months (m)) and variations in arterial structure, stiffness and hemodynamics at age 6 years. Second, to determine whether the associations depend on exposure to cardiovascular risk factors, body size at birth and/or on body size at the time of the evaluation (cofactors). Anthropometric (at birth, 6, 12, 24, 36 m and at age 6 years), hemodynamic (peripheral and central (aortic)) and arterial (elastic (carotid) and muscular (femoral) arteries; both hemi-bodies) parameters were assessed in a child cohort (6 years; n =632). The association between arterial parameters and body size changes (Δz-BW, Δz-BH, Δz-BWH, Δz-BMI) in the different growth periods was compared, before and after adjustment by cofactors. Results: Δz-BW 0–24 m and Δz-BWH 0–24 m allowed us to explain inter-individual variations in structural arterial properties at age 6 years, with independence of cofactors. When the third year of life was included in the analysis (0–36, 12–36, 24–36 m), Δz-BW explained hemodynamic (peripheral and central) variations at age 6 years. Δz-BH and Δz-BMI showed limited associations with arterial properties. Conclusion: Δz-BW and Δz-BWH are the anthropometric variables with the greatest association with arterial structure and hemodynamics in early childhood, with independence of cofactors.

Remodeling of Retinal Microcirculation Is Associated With Subclinical Arterial Injury in Hypertensive Children

[Figure: see text].

Prevalence trends of hypertension among 9-17 aged children and adolescents in Yunnan, 2017-2019: a serial cross-sectional surveillance survey

BACKGROUND

We aim to describe the prevalence and trends of hypertension among 9-17 school-aged students from 2017 to 2019 in Yunnan, China.

METHODS

We conducted a cross-sectional study by using data from the Students' Health Surveillance Surveys of 2017, 2018 and 2019 in Yunnan. The Students' Health Surveillance Surveys in Yunnan collected date on physical fitness and health status of students in Yunnan through multistage-stratified sampling in 3 prefectures. In each prefecture, the study population were classified by gender and region (urban or rural), and each group had an equal size. Diagnosing criteria of hypertension was set with reference to Chinese age-specific and height-specific blood pressure (BP), to identify the abnormal status of boys and girls separately. ANOVA test was adopted to measure the differences in the mean BP stratified by gender, age, prefecture and area, and Chi-square test was used to compare the percentages of hypertension in different areas. For comparability, the age-standard and gender-standard population prevalence was calculated by directly using China Census in 2010 as a standard population. Totally 24,890 participants aged 9-17 years were included in this study.

RESULTS

From 2017 to 2019, there were 24,872 students completed physical examinations and included in the analysis, of which 3288 were diagnosed with hypertension. The total prevalence of hypertension was 13.72, 12.49 and 13.45% among 9-17 years school-aged population in Yunnan, respectively. The total age-standardized hypertension prevalence trended to decrease from 13.82 to 13.48%. For urban population, the age-standardized hypertension prevalence decreased slightly from 11.24 to 10.13%. While, for rural population, it increased from 17.58 to 19.16%. The average annual growth rate in rural population was 0.53%.

CONCLUSIONS

From 2017to 2019, there was a significant and continuous increase in the prevalence of hypertension in 9-17 years school-aged population in Yunnan. Hypertension is epidemic among children and adolescents in Yunnan. We should take effective and comprehensive intervention measures to reduce its prevalence among school-aged children.

Life-Course Implications of Pediatric Risk Factors for Cardiovascular Disease

The concept that origins of cardiovascular disease (CVD) begin in childhood is supported by substantial evidence. Prospective studies beginning in childhood report associations of childhood obesity, abnormal blood pressure (BP), dyslipidemia, diabetes, and tobacco use with intermediate CVD markers, including left ventricular hypertrophy and vascular stiffness in young adulthood. Trajectory analyses from longitudinal studies describe discrete BP pathways from childhood to young adult status of hypertension and prehypertension. Among individuals with familial hypercholesterolemia, abnormal low-density lipoprotein cholesterol levels are present in childhood. Some children are at risk for future CVD owing to hereditary factors, psychosocial stress, race, low birth weight, or other nonmodifiable exposures. Behavioural factors, including suboptimal diet, sedentary activity, and tobacco use, in childhood augment risk and can be modified to reduce risk. Pharmacologic treatments are reserved for those at high levels of the BP and cholesterol distributions and for those with diabetes and additional risk factors.

Utility of blood pressure measurements at an initial screening visit to identify Chinese children and adolescents with hypertension

The performance of different BP readings and their combinations at a visit to identify children and adolescents with pediatric hypertension remains controversial. We aimed to assess the utility of different blood pressure (BP) readings and their combinations obtained at the initial screening visit for identifying Chinese children and adolescents with hypertension. Participants were 7831 children and adolescents aged 6‐17 years measured as part of a cross‐sectional survey conducted in Jinan, China between September 2012 and November 2014. BP was measured three times at up to three visits. Elevated BP at the initial visit was defined as systolic BP and/or diastolic BP ≥ age‐ and sex‐specific 95th percentiles using the Chinese BP references for children and adolescents based on different BP readings and their combinations. Participants with elevated BP using (BP2+BP3)/2 across three visits were defined as having hypertension. Of the different readings or combinations examined, the mean of the last two readings at the initial visit had the best predictive utility for children and adolescents with hypertension (sensitivity: 100.0%; specificity: 86.9%; positive predictive value: 27.6%; negative predictive value: 100.0%). This was also reflected in the area under the curve being highest for the mean of the last two readings (0.93, 95% confidence interval: 0.93‐0.94) compared with any of the other readings or combinations (BP1, BP2, BP3, [BP1+BP2]/2, [BP1+BP3]/2, and [BP1+BP2+BP3]/3; all p < .001). Taking three measurements of BP and using the average of the last two readings at a screening visit may be optimal for the identification of hypertension in youth.

Eccentric Left Ventricular Hypertrophy and Left and Right Cardiac Function in Chronic Heart Failure with or without Coexisting COPD: Impact on Exercise Performance

AIM

Our aim was to assess: 1) the impact of the eccentric left ventricular hypertrophy (ELVH) on exercise performance in patients diagnosed with chronic heart failure (CHF) alone and in patients with co-existing CHF and chronic obstructive pulmonary disease (COPD) and 2) the relationship between left and right cardiac function measurements obtained by doppler echocardiography, clinical characteristics and primary measures of cardiorespiratory fitness.

METHODS

The current study included 46 patients (CHF:23 and CHF+COPD:23) that performed advanced pulmonary function tests, echocardiography and symptom-limited, incremental cardiopulmonary exercise testing (CPET) on a cycle ergometer.

RESULTS

Patients with CHF+COPD demonstrated a lower work rate, peak oxygen uptake (VO2), oxygen pulse, rate pressure product (RPP), circulatory power (CP) and ventilatory power (VP) compared to those only diagnosed with CHF. In addition, significant correlations were observed between VP and relative wall thickness (r: 0.45 p: 0.03),VE/VCO2 intercept and Mitral E/e' ratio (r: 0.70 p: 0.003) in the CHF group. Significant correlations were found between indexed left ventricle mass and RPP (r: -0.47; p: 0.02) and relative VO2 and right ventricle diameter (r: -0.62; p: 0.001) in the CHF+COPD group.

CONCLUSION

Compared to a diagnosis of CHF alone, a combined diagnosis of CHF+COPD induced further impairments in cardiorespiratory fitness. Moreover, echocardiographic measures of cardiac function are related to cardiopulmonary exercise performance and therefore appear to be an important therapeutic target when attempting to improve exercise performance and functional capacity.

The Predictors of Hypertension in Children: Palestinian Perspective

Method

Cross-sectional study was performed on five hundred and nine (10–13) year old students from governmental schools in Jenin and Tubas. Anthropometric measures consist of body mass index, hip circumference (HC), waist circumference (WC), the ratio of waist to hip (WHR), and the ratio of waist to height (WHtR) were measured. Blood pressure was assessed including systolic (SBP) and diastolic (DBP) utilizing a (Dynamap) vital signs monitor.

Results

Approximately 38.7% of participants (38.8% females and 38.63% males) were considered pre-hypertensive and 7.3% of the participants (7.4% females and 7.1% males) were hypertensive. Also, there was a weak to moderate relationship between mean blood pressure (systolic and diastolic) and the anthropometric measurements. Additionally, most predictors with significant effects on early childhood hypertension were body mass index (OR 1.16, 95% CI 1.09–1.23).

Conclusions

Hypertension and prehypertension are present in Palestinian children. Waist hip ratio is the greatest predictor of BP, followed by body mass index. Hence, weight-reduction strategies to at-risk children are crucial to minimizing the prevalence of Palestinian childhood hypertension.