Regression of left ventricular hypertrophy in children with antihypertensive therapy

Association between lifestyle modifications and improvement of early cardiac damage in children and adolescents with excess weight and/or high blood pressure

BACKGROUND

It is not known whether, in children and adolescents with alterations in weight and/or blood pressure (BP), lifestyle modifications are associated with an improvement of early cardiac damage.

METHODS

In a pediatric population referred for excess weight, high BP, or both (n = 278, 10.6 (2.3) years), echocardiography was performed at enrollment and after 15 months of follow-up, during which participants received nonpharmacological treatment, based on correcting unhealthy lifestyles and improving dietary habits. Left ventricular mass was indexed for height (g/m2.7, LVMI), and an LVMI value higher than or equal to age- and gender-specific 95th percentile was the criterion for defining left ventricular hypertrophy (LVH). Multiple linear and logistic regression analyses were carried out to determine associations between changes in BMI and BP z-scores and changes of LVMI values and LVH prevalence, from baseline to follow-up.

RESULTS

At baseline, 33.1% of study participants were hypertensive, 52.9% obese, and 36.3% had LVH. At follow-up, the prevalence of hypertension, obesity, and LVH was 18.7%, 30.2%, and 22.3%, respectively (p < 0.001 for all). A decrease in LVMI from 37.1 to 35.2 g/m2.7 (p < 0.001) was observed. Only delta BMI z-score positively related to an improvement of LVMI. Reductions of BMI (OR = 0.22, 95% CI 0.07-0.64) and diastolic BP (OR = 0.64, 95% CI 0.42-0.93) z-scores from baseline to follow-up and family history of hypertension (OR = 0.36, 95% CI 0.16-0.78) were associated with a lower prevalence of LVH.

CONCLUSIONS

In a pediatric population at cardiovascular risk, changing incorrect lifestyle and dietary habits is associated with both reduction of BMI and BP values and regression of early cardiac damage. A higher resolution version of the Graphical abstract is available as Supplementary information.

The predictive value of repeated blood pressure measurements in childhood for cardiovascular risk in adults: the Hanzhong Adolescent Hypertension Study

There is currently a lack of strong evidence linking childhood elevated blood pressure to long-term cardiovascular risk in adulthood. Repeated observations of abnormal blood pressure in childhood may enhance the prediction of cardiovascular risk in adulthood compared with a single observation. The study included 1738 individuals in rural areas of Hanzhong City, Shaanxi, who had been followed for 30 years since baseline (1987, at which time participants were aged 6-15 years). According to four independent measurements of blood pressure in 1987, 1989, 1992, and 1995, childhood elevated blood pressure was defined as 2 in-person examinations with blood pressure values above the 90th percentile. Arterial stiffness and left ventricular hypertrophy in adulthood were assessed by brachial-ankle pulse wave velocity and the Cornell product index, respectively. Childhood elevated blood pressure was associated with an increased risk of adult hypertension (OR, 2.01; 95% CI, 1.53-2.65), arterial stiffness (OR, 1.69; 95% CI, 1.32-2.16) and left ventricular hypertrophy (OR, 1.86; 95% CI, 1.13-3.05) (all P < 0.05). Cardiovascular risk in adults increased with increasing childhood blood pressure levels. In addition, two abnormal childhood blood pressure observations predicted an increased likelihood of hypertension in adulthood (0.77 for 2 versus 0.70 for 1 observation, P < 0.001). Our study provides strong evidence that elevated blood pressure in childhood predicts cardiovascular risk in adults. The prediction was enhanced by two observations of abnormal blood pressure in childhood compared with a single measurement. We emphasize the importance of childhood blood pressure monitoring and control in the prevention of cardiovascular diseases.

Hypertension in pediatric patients with chronic kidney disease: management challenges

In contrast to adults where hypertension is a leading cause of chronic kidney disease, in pediatrics, hypertension is predominantly a sequela, however, an important one that, like in adults, is likely associated with a more rapid decline in kidney function or progression of chronic kidney disease to end stage. There is a significant issue with unrecognized, or masked, hypertension in childhood chronic kidney disease. Recent evidence and, therefore, guidelines now suggest targeting a blood pressure of <50th percentile for age, sex, and height in children with proteinuria and chronic kidney disease. This often cannot be achieved by monotherapy and additional agents need to be added. Blockade of the renin angiotensin aldosterone system represents the mainstay of therapy, although often limited by the side effect of hyperkalemia. The addition of a diuretic, at least in the earlier stages of chronic kidney disease, might help mitigate this problem.

Relationship of ambulatory blood pressure and body mass index to left ventricular mass index in pediatric patients with casual hypertension

Both obesity and hypertension are associated with left ventricular hypertrophy (LVH) in children. Our objective was to compare the prevalence of LVH in obese and nonobese subjects with casual hypertension who underwent ambulatory blood pressure monitoring (ABPM). Untreated children (aged 6-20 years) underwent 24-hour ABPM, and left ventricular mass index (LVMI) was measured. Subjects were classified into three groups: white coat hypertension (WCH), prehypertension (pre-HT), and hypertension (HT). The prevalence of LVH was compared between obese and nonobese subjects among the groups. Of 69 children who underwent ABPM, thirty-two patients (46%) had WCH, 13 (19%) had pre-HT, and 24 (35%) had HT. Mean age, BMI, and LVMI were similar in the groups (P = not significant [NS]). In all, 22 patients (32%) had LVH, with no difference among WCH versus pre-HT versus HT (37.5% vs. 46% vs. 16.7%, P = NS). Twenty-seven subjects (39%) were obese. The ratio of LVH in obese to nonobese was 55.5% to 16.6% (P = .001). In both pre-HT and WCH, patients with LVH had a significantly higher BMI z score (P = .02 and P = .01, respectively). LVMI correlated strongly with BMI z score (P = .0001) but not with any blood pressure parameter. Almost half of children with casual HT have WCH. LVH is prevalent in a third of children with HT, pre-HT, and WCH. In both pre-HT and WCH, patients with LVH were more likely to be obese. More than half of all the obese subjects had LVH. Obese children in all three groups may be at a greater risk for end organ damage.

Change in cardiac geometry and function in CKD children during strict BP control: a randomized study

BACKGROUND AND OBJECTIVES

Left ventricular hypertrophy (LVH) and abnormal systolic function are present in a high proportion of children with CKD. This study evaluated changes in left ventricular (LV) geometry and systolic function in children with mild to moderate CKD as an ancillary project of the Effect of Strict Blood Pressure Control and ACE Inhibition on Progression of Chronic Renal Failure in Pediatric Patients trial.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Echocardiograms and ambulatory BP monitoring were performed at baseline and at 1- or 2-year follow-up in 84 patients with CKD and 24-hour mean BP above the 50th percentile and/or receiving fixed high-dose angiotensin converting enzyme inhibition and randomized to conventional or intensified BP control.

RESULTS

LVH prevalence decreased from 38% to 25% (P<0.05). Changes in LV mass index (LVMI) were restricted to patients with LVH at baseline (-7.9 g/m(2.7); P<0.02). Changes in LVMI were independent of randomization, reduction in BP, hemoglobin, and estimated GFR. A significant increase in midwall fractional shortening was observed in the total cohort (P<0.05), and was greater in the intensified group compared with the conventional BP control group (12%±1.9% versus 8%±1.5%; P=0.05). In multivariate analysis, improvement in myocardial function was associated with reduction in BP (r=-0.4; P<0.05), independently of LVMI reduction.

CONCLUSIONS

In children with CKD, angiotensin converting enzyme inhibition with improved BP control, LVH regression, and improved systolic function was observed within 12 months. Lowering BP to the low-normal range led to a slightly more marked improvement in myocardial function but not in LVMI.

Control of hypertension in treated children and its association with target organ damage

BACKGROUND

The aim of our study was to investigate the control of hypertension (HT) in treated children using ambulatory blood pressure (BP) monitoring (ABPM).

METHODS

We retrospectively reviewed all ABPM studies in our center. Controlled HT was defined as systolic and diastolic BP index (patients' BP divided by the 95th percentile) at daytime and nighttime <1.0 or alternatively as BP load (percentage of BP readings above the 95th percentile) <25% in children on antihypertensive therapy.

RESULTS

A total of 195 ABPM studies were included. The mean age was 13.6 ± 4.0 years. One hundred and thirty two children had renoparenchymal HT, 10 renovascular (RVH), 10 endocrine, 4 cardiovascular, 29 primary (PH) and 5 children other forms of HT. 53% of all children had controlled HT. There was no difference in the prevalence of controlled HT between primary and secondary HT (52% and 53%) using the BP index criterion. Children with renoparenchymal HT had significantly better control of HT than children with RVH (58% vs. 20% P = 0.02). The use of angiotensin-converting enzyme inhibitors (ACEI) monotherapy was significantly more effective in controlling HT than the use of calcium-channel blockers (CCB, P = 0.02). The prevalence of left ventricular hypertrophy in children with uncontrolled HT (assessed in 58 patients) was significantly higher than in children with controlled HT (46% vs. 13%, P < 0.01).

CONCLUSIONS

This is the first pediatric study, to our knowledge, on BP control in hypertensive children using ABPM. It indicates that control of HT is inadequate in ~50% of treated children. Inadequate control of HT is associated with target organ damage in this population.

Improvement of left ventricular mass with antihypertensive therapy in children with hypertension

There is paucity of data on the regression of left ventricular hypertrophy (LVH) in hypertensive children. This study assessed the effects of antihypertensive therapy on left ventricular mass in children with and without LVH. Medical records of hypertensive patients who had a baseline and follow-up echocardiogram (echo 1, echo 2) were reviewed. Fifteen of 22 treated patients had LVH at echo 1. Enalapril alone or combined was used in 21/22 cases. Echo 2 was performed at a mean interval of 15 +/- 7 months. The LVH group showed significant decrease in systolic blood pressure z-score (SBPZ) (2.89 +/-1.61 to 1.40 +/- 1.19; p=0.01), diastolic blood pressure z-score (DBPZ) (1.44 +/- 0.90 to 0.26 +/- 0.82; p<0.001), and LV mass index (LVMI) (56.2 +/- 12.50 to 43.7 +/- 8.30; p=0.001), but no significant change in body mass index z-score (BMIZ) (1.79 +/- 0.75 to 1.69 +/- 0.69; p=0.74). In the no-LVH group, SBPZ (3.03 +/- 1.68 to 2.27 +/- 1.81; p=0.356), DBPZ (1.00 +/- 0.87 to 0.63 +/- 0.68; p=0.409), BMIZ (1.08 +/- 0.98 to 1.27 +/- 0.89; p=0.672), and LVMI (29.47 +/- 5.51 to 33.89 +/ -3.06;p=0.374) did not change significantly. Simple linear regression demonstrated that the change in LVMI in the combined group had a significant correlation (r=0.477; p=0.025) with the percentage change in SBPZ. This study demonstrates that LVH in hypertensive children improves with effective blood pressure control.

Relation of left ventricular hypertrophy to microalbuminuria and C-reactive protein in children and adolescents with essential hypertension

Microalbuminuria (MA) and C-reactive protein (CRP) levels are predictors of increased risk for left ventricular hypertrophy (LVH). Whether the strength of association between CRP and LVH is comparable to that of MA in hypertensive children is unknown. CRP and MA were measured in 64 children and adolescents with essential hypertension (HTN). In the entire population, CRP and MA showed positive relations with body mass index (BMI) (r = 0.30, p = 0.04 and r = 0.32, p = 0.04, respectively), systolic blood pressure (SBP) (r = 0.63, p = 0.03 and r = 0.58, p = 0.03, respectively), and LVH (r = 0.86, p < 0.001 and r = 0.81, p < 0.001, respectively). Patients with LVH (n = 23) had significantly higher BMI (p = 0.32), increased SBP (p = 0.031), and higher levels of CRP (p < 0.001) and MA (p < 0.001) compared with those without LVH. Multiple linear regression analysis demonstrated that CRP (r = 2.11, p < 0.001), MA (r = 1.94, p < 0.003), BMI (r = 0.53, p = 0.02), and SBP (r = 0.48, p = 0.04) were significantly associated with LVH. By analysis of covariance, CRP and MA were significantly different between patients who had LVH and those without LVH after adjustment for age, gender, BMI, SBP, SBP index, and diastolic blood pressure (p < 0.001 for the two markers). In conclusion, the strength of association between LVH and CRP is comparable to that of MA in children and adolescents with essential HTN.

C-reactive protein and incident left ventricular hypertrophy in essential hypertension

Elevated C-reactive protein (CRP) levels have been associated with increased cardiovascular risk in hypertensive adults. The aim of this study was to determine whether plasma CRP level is more predictive of left ventricular hypertrophy (LVH) than is ambulatory blood pressure (BP) in hypertensive children. Baseline and 12-month follow-up measures of BP, body mass index (BMI), low-density lipoprotein/high density lipoprotein cholesterol, left ventricular mass (LVM), and CRP data collected from 48 newly diagnosed, untreated hypertensive children were analyzed. CRP was measured by a highly sensitive nephelometric method. Left ventricular mass index (LVMI) was calculated as LVM/height2.7, and LVH was defined as LVMI>38.6 g/m2.7 being the cut-point for the 95th percentile found in healthy children. Average systolic BP (SBP), diastolic BP (DBP), SBP index, and DBP index were calculated. All patients received hydrochlorothiazide therapy in combination with angiotensin converting enzyme inhibitor treatment. Five patients also had angiotensin receptor blocker therapy to reach the target BP (<95th percentile corrected for age and gender). In a multiple regression analysis, LMVI was correlated with CRP, BMI, SBP, and SBP index. CRP alone explained 77% of the variance of LVMI, whereas BMI, SBP, and SBP index explained only 1.3, 0.3, and 0.4% of the variance, respectively. CRP was also the most significant correlate of follow-up LVH. In conclusion, elevated CRP level is significantly associated with LVH in children with essential hypertension. BP reduction with renin-angiotensin system blocker and hydrochlorothiazide therapy reduces LVH while lowering CRP level.