Primary hypertension at a single center: treatment, time to control, and extended follow-up

The ongoing impact of obesity on childhood hypertension

Obesity rates among children have been steadily rising over the past several decades. This epidemic has been accompanied by an increase in the prevalence of childhood hypertension, with children in low- and middle-income countries being affected to the same extent as children in high-income countries. This review will examine the trends in childhood blood pressure and the relationship between excess body weight and the development of hypertension. In addition, distinct mechanisms of obesity-related hypertension will be discussed. There will be an emphasis on recent studies conducted since the publication of new guidelines by the American Academy of Pediatrics in 2017 which resulted in the adoption of lower normative blood pressure cutoffs. The overall intent of this review is to provide the reader with an understanding of the ongoing impact, and complexities, of obesity-related hypertension.

School-Based Telemedicine for Hypertension Management in Urban Adolescents

PURPOSE

The aim of this study is to determine if hypertensive adolescents from impoverished neighborhoods in Rochester, New York have improved blood pressure (BP) control with the use of school-based telemedicine.

METHODS

Adolescents receiving antihypertensive medication had monthly study telemedicine visits at school. BP was measured by a telehealth clinical assistant (CTA) at the school using standard procedures, followed in real time by a teleconferencing visit with the study physician.

RESULTS

Six participants were enrolled, and all completed school-based telemedicine visits prior to school closure due to the SARS-CoV-2 pandemic. Mean systolic and diastolic BP at baseline were 139 ± 5 and 75 ± 8 mmHg. All six participants had significant improvement in their blood pressure (final school mean BPs, 127 ± 4 and 67 ± 5 mmHg; systolic, baseline vs. final, p = .003).

DISCUSSION

In this pilot study, adolescents with very high levels of neighborhood disadvantage had consistent adherence with school-based telemedicine and significant improvement in hypertension (HTN) control.

Antihypertensive therapy of late arterial hypertension in children following successful coarctation correction

BACKGROUNG

Late arterial hypertension (AH) is the most significant complication of coarctation of the aorta (CoA). Only a few clinical studies described antihypertensive treatment of late AH following successful CoA repair. The primary objective of this multicentre cross-sectional study was to describe real-life antihypertensive therapy for late AH in children after hemodynamically successful CoA repair. The secondary objective was to describe antihypertensive therapy used within different haemodynamic phenotypes of AH.

METHOD

Blood pressure status, echocardiographic parameters and central blood pressure measurements were evaluated in 110 children aged 6-18 years following successful CoA repair with right arm blood pressure not exceeding leg blood pressure by at least 20 mmHg.

RESULTS

AH was found in 62 (56%) patients including 47 who were already treated and 15 with new diagnosed AH of whom seven presented with masked hypertension. Among treated patients, 10 presented with masked hypertension. The dominant phenotype of AH among patients with uncontrolled AH was isolated systolic hypertension (32 patients out of 37; 87.5%). AH was controlled in 53% of treated patients. Fifty-three percent of hypertensive patients had elevated central SBP and 39% had left ventricular hypertrophy with various left ventricle geometry patterns, 23% of them had both. β-adrenergic receptor blockers were the most used antihypertensive drugs followed by angiotensin-converting enzyme inhibitors with doses within the lower recommended range.

CONCLUSION

High prevalence of uncontrolled AH despite successful CoA repair and use of relatively low doses of antihypertensive drugs indicates the need of close blood pressure monitoring and more intensive and combined antihypertensive therapy.

When Hypertension Grows Up: Implications for Transitioning Care of Adolescents and Young Adults With Hypertension From Pediatric to Adult Health Care Providers

Hypertension (HTN) is an important cause of morbidity and mortality in children as well as adults. HTN and related adverse cardiovascular health develop and progress on a continuum across an individual's life course. Pediatric HTN, or even isolated elevated blood pressure as a child, increases the risk of sustained HTN and cardiovascular disease in later adulthood. Transitioning the care of adolescents and young adults who have HTN is an important but unmet health care need that could potentially have a dramatic effect on mitigating the risk of cardiovascular disease in adulthood. However, very little has been published about the transition process in this population, and considerable gaps in the field remain. We discuss the epidemiology, etiology, and management approach in youth with HTN and how they differ from adults. We contextualize HTN and cardiovascular health on a continuum across the life course. We discuss key considerations for the transition process for adolescents and young adults with HTN including the major barriers that exist. Finally, we review key immediate health care needs that are particularly important around the time of the transfer of care.

Challenges in choosing the appropriate guidelines for use in children and adolescents with hypertension

BACKGROUND

This study was designed to observe the effect of antihypertensive treatment on blood pressure (BP) and target organ damage in patients followed up according to the American Academy of Pediatrics Hypertension Guidelines (AAPG). The results were also assessed in comparison with the definitions and target organ damage according to the European Society of Hypertension Guidelines 2016 (ESHG).

MATERIALS AND METHODS

A total of 44 (34 male) out of 140 patients were enrolled in the study and the mean age was 14±3.19years. The follow-up period was at least 12months. All patients underwent the following assessments: anthropometrical measurements of body mass index (BMI), left ventricular mass index (LVMI), and biochemical parameters according to the relevant guidelines. The pre-treatment and post-treatment datasets collected were compared.

RESULTS

The frequency of symptomatic patients decreased from 88% to 30%. After treatment, 29.4% (n=13) of patients still had elevated and stage 1 hypertension (HT) according to the AAPG. These patients were older and had higher BMI z-scores, LVMI z-scores, mean BP indices, and also had longer symptom duration than normotensive patients (P<0.001). When patients were assessed according to the ESHG, 34.1% (n=15) of patients had high-normal stage 1 and stage 2 HT. While 53.3% (n=8) of the patients aged 13-15years were classified as having high-normal stage 1 and stage 2 HT according to the ESHG, 33.3% (n=5) were classified as having elevated BP and stage 1 HT according to the AAPG. Additionally, 36.4% (n=4) of the patients aged≥16years were classified as having high-normal and stage 1 HT according to the ESHG, whereas 45.5% (n=5) were classified as having elevated BP and stage 1 HT according to the AAPG.

CONCLUSION

To control HT in children with higher BMI z-scores, higher LVMI z-scores, and higher BP indices, an earlier and more intensive approach is needed. Considering that the duration of exposure to HT may also affect the LVMI, adjusting age and gender or decreasing the current thresholds for LVMI may lead to an earlier diagnosis for more patients. According to the present classifications, the ESHG covers more children aged between 13 and 15years in contrast to the AAPG, which covers more patients aged≥16years. However, further studies are needed to confirm these results.

The Prevalence and Risk Factors of Hypertension among the Urban Population in Southeast Asian Countries: A Systematic Review and Meta-Analysis

The trend of global prevalence for hypertension has been dramatically increasing for the past two decades in Southeast Asian countries. A systematic review aiming to assess the prevalence of hypertension and its risk factors among the urban population in Southeast Asian countries was conducted. We performed database searches of PubMed and Web of Science and performed meta-analysis to determine the pooled prevalence estimate. The overall pooled prevalence estimate of hypertension for Southeast Asian urban population was 33.82%. Among this, 33.98% of hypertension was reported in the community and 32.45% among adolescents in school. The common risk factors that we found were male, ethnicity, education and socioeconomic level, body mass index, waist circumference, smoking, and dyslipidaemia. The review indicates an urgent need for primary and secondary prevention activities. Therefore, a multisectoral and intersectoral approach and collaboration should be undertaken to improve the overall health outcomes of all populations in all Southeast Asian countries.

The Impact of Early Recognition and Treatment of Systemic Hypertension on Reducing Blood Pressure: The Hypertension and Vascular Evaluation Program

This study aimed to evaluate the effect of an outpatient systemic hypertension program and associated factors with attending recommended follow-up visit. All visits were tracked in the program, 2011 to 2018. We examined patient characteristics by follow-up status and changes in systolic blood pressure (SBP) and the risk of hypertension in follow-up patients using a mixed-effects regression model. Among 310 patients with first visits, 113 patients returned for a follow-up visit. Patients who did not attend a follow-up were older and less likely to have a severe chronic condition or a family history of hypertension than followed-up patients. The risk of hypertension was significantly reduced by the number of follow-up visits (odds ratio = 0.53, 95% confidence interval = 0.31-0.92). Adolescent SBP and body mass index percentiles decreased with more follow-up visits. As the risk of hypertension is significantly reduced with follow-up visits, additional effort should be made to improve the likelihood of follow-up attendance.

Neurocognitive Function in Children with Primary Hypertension after Initiation of Antihypertensive Therapy

OBJECTIVE

To determine the change in neurocognitive test performance in children with primary hypertension after initiation of antihypertensive therapy.

STUDY DESIGN

Subjects with hypertension and normotensive control subjects had neurocognitive testing at baseline and again after 1 year, during which time the subjects with hypertension received antihypertensive therapy. Subjects completed tests of general intelligence, attention, memory, executive function, and processing speed, and parents completed rating scales of executive function.

RESULTS

Fifty-five subjects with hypertension and 66 normotensive control subjects underwent both baseline and 1-year assessments. Overall, the blood pressure (BP) of subjects with hypertension improved (24-hour systolic BP load: mean baseline vs 1 year, 58% vs 38%, P < .001). Primary multivariable analyses showed that the hypertension group improved in scores of subtests of the Rey Auditory Verbal Learning Test, Grooved Pegboard, and Delis-Kaplan Executive Function System Tower Test (P < .05). However, the control group also improved in the same measures with similar effects sizes. Secondary analyses by effectiveness of antihypertensive therapy showed that subjects with persistent ambulatory hypertension at 1 year (n = 17) did not improve in subtests of Rey Auditory Verbal Learning Test and had limited improvement in Grooved Pegboard.

CONCLUSIONS

Overall, children with hypertension did not improve in neurocognitive test performance after 1 year of antihypertensive therapy, beyond that also seen in normotensive controls, suggesting improvements with age or practice effects because of repeated neurocognitive testing. However, the degree to which antihypertensive therapy improves BP may affect its impact upon neurocognitive function.

Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents

These pediatric hypertension guidelines are an update to the 2004 "Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents." Significant changes in these guidelines include (1) the replacement of the term "prehypertension" with the term "elevated blood pressure," (2) new normative pediatric blood pressure (BP) tables based on normal-weight children, (3) a simplified screening table for identifying BPs needing further evaluation, (4) a simplified BP classification in adolescents ≥13 years of age that aligns with the forthcoming American Heart Association and American College of Cardiology adult BP guidelines, (5) a more limited recommendation to perform screening BP measurements only at preventive care visits, (6) streamlined recommendations on the initial evaluation and management of abnormal BPs, (7) an expanded role for ambulatory BP monitoring in the diagnosis and management of pediatric hypertension, and (8) revised recommendations on when to perform echocardiography in the evaluation of newly diagnosed hypertensive pediatric patients (generally only before medication initiation), along with a revised definition of left ventricular hypertrophy. These guidelines include 30 Key Action Statements and 27 additional recommendations derived from a comprehensive review of almost 15 000 published articles between January 2004 and July 2016. Each Key Action Statement includes level of evidence, benefit-harm relationship, and strength of recommendation. This clinical practice guideline, endorsed by the American Heart Association, is intended to foster a patient- and family-centered approach to care, reduce unnecessary and costly medical interventions, improve patient diagnoses and outcomes, support implementation, and provide direction for future research.

Disparities in antihypertensive medication adherence in adolescents

BACKGROUND

Hypertension affects up to 5 % of all children, but little is known about the role of medication adherence on blood pressure (BP) control. In this study we examined the association between adolescents' antihypertensive medication adherence and BP control, investigating for racial disparities.

METHODS

A total of 21 adolescents with essential hypertension [mean age 14.7 ± 2.0 years, 57 % male, 52 % African American] were recruited from a pediatric nephrology clinic. Objective medication adherence measures were obtained with Medication Event Monitoring System (MEMS) caps and pharmacy refill records to determine medication possession ratios (MPRs).

RESULTS

The African Americans adolescents had lower medication adherence than non-African Americans adolescents based on the MPR over the past 12 months (mean 0.54 ± 0.21 vs. 0.85 ± 0.16, respectively; p < 0.001) and a trend for less adherence measured by MEMS caps over the last 28 days (mean 0.75 ± 0.26 vs. 0.91 ± 0.04, respectively; p < 0.07). Seven of the eight participants with low adherence (MPR <0.65) had uncontrolled BP (systolic and/or diastolic BPs ≥ 95th percentile), and no participants with high adherence according to the MPR had uncontrolled BP (p < 0.001). There was no difference in BP control by race.

CONCLUSIONS

Antihypertensive medication adherence measured by pharmacy refills was associated with BP control. AAs were more likely to have lower medication adherence. Targeting medication adherence through the use of electronic medical records may be a potential mechanism to reduce health disparities.

Long-term control of ambulatory hypertension in children: improving with time but still not achieving new blood pressure goals

BACKGROUND

Short-term therapy can decrease blood pressure (BP) to less than the 95th percentile in only about 50% of children. The aim of our study was to investigate the long-term control of hypertension (HT) in children using ambulatory BP monitoring (ABPM).

METHODS

We analyzed data from all children who started ramipril monotherapy in our center. Controlled HT was defined according to the most current guidelines as systolic and diastolic BP at daytime and nighttime <90th percentile in primary HT and <75th percentile in renoparenchymal HT.

RESULTS

Thirty-eight children who were on therapy ≥1 year were included. Thirty-two children had renoparenchymal, and 6 had primary HT. The median age at the beginning of therapy was 13.6 years (range = 4.1-18.0 years), and the median time of antihypertensive therapy was 2.6 years (range = 1.0-11.8 years). Thirty-four percent of children received combination therapy; the median number of antihypertensive drugs was 1.5 drugs/patient (range = 1-4). Sixty-eight percent of children had BP <95th percentile, but only 34% of the children had controlled HT. Children with uncontrolled HT had a tendency to have a higher daytime diastolic BP index before the start of therapy than children with controlled HT (0.99±0.11 vs. 0.94±0.11; P = 0.09). There was a significant decrease in prevalence of nondipping (from 47% to 16%; P = 0.006) with therapy.

CONCLUSIONS

This first pediatric study focusing on long-term control of HT using ABPM showed that long-term control of HT is better than short-term control, but still only one-third of children achieve the new BP goals. The low control of HT might be improved by more intensive therapy.

Primary versus secondary hypertension in children followed up at an outpatient tertiary unit

Childhood hypertension has classically been recognized as a secondary disease. However, primary hypertension also occurs in children. The aim of this study was to compare clinical features of pediatric patients with elevated blood pressure, which were referred to an outpatient tertiary unit, and to detect variables associated with the identification of primary hypertension. The records of 220 patients with hypertension followed between 1996 and 2006 were analyzed. The variable of interest was primary hypertension. Logistic regression analysis was applied to identify clinical variables that were independently associated with primary hypertension. Of 220 patients, 33 (15%) had primary hypertension, and 187 (85%) exhibited secondary hypertension. No statistically significant differences were detected in gender, race, age at diagnosis, and systolic/diastolic blood pressure levels between both groups. After adjustment, four variables at baseline remained independently associated with primary hypertension: absence of signs/symptoms (OR 18.87, 95% CI 6.32-56.29), normal serum creatinine (OR 0.02, 95% CI 0.00-0.27), family history of hypertension (OR 3.03, 95% CI 1.04-8.79), and elevated body weight (OR 1.06, 95% CI 1.02-1.10). The absence of signs/symptoms, normal serum creatinine, family history of hypertension, and overweight/obesity at admission are clues to diagnose primary hypertension in childhood.