A 15-year longitudinal study on ambulatory blood pressure tracking from childhood to early adulthood. Hypertens Res. 2009;32:404-410. [PMID: 19325561 DOI: 10.1038/hr.2009.32]

Measurement of Blood Pressure in Children and Adolescents Outside the Office for the Diagnosis of Hypertension

PURPOSE OF REVIEW

To review the benefits of ambulatory blood pressure monitoring and home blood pressure monitoring in children and to discuss implementation of guideline-recommended ambulatory blood pressure monitoring.

RECENT FINDINGS

Compared with office blood pressure, ambulatory blood pressure monitoring and home blood pressure monitoring provide superior accuracy, reproducibility, and stronger associations with target organ damage although future work is needed to determine the utility of home blood pressure monitoring to predict hypertension status on ambulatory blood pressure monitoring. Due to the benefits of out-of-office blood pressure measurement, ambulatory blood pressure monitoring has been recommended to confirm the diagnosis of hypertension in children and adolescents since publication of the 2017 American Academy of Pediatrics clinical practice guidelines on hypertension. However, access to ambulatory blood pressure monitoring remains limited to the subspecialty setting and novel care pathways are needed to improve guideline-concordant use of ambulatory blood pressure monitoring. Nocturnal home blood pressure monitoring may be a practical alternative when ambulatory blood pressure monitoring is not available.

Predictors of Psychological Strain and Allostatic Load in Teachers: Examining the Long-Term Effects of Biopsychosocial Risk and Protective Factors Using a LASSO Regression Approach

Teacher stress significantly challenges teachers' health, teaching quality, and students' motivation and achievement. Thus, it is crucial to identify factors that effectively prevent it. Using a LASSO regression approach, we examined which factors predict teachers' psychological strain and allostatic load over two years. The study included 42 teachers (28 female, Mage = 39.66, SD = 11.99) and three measurement time points: At baseline, we assessed teachers' (a) self-reports (i.e., on personality, coping styles, and psychological strain), (b) behavioral data (i.e., videotaped lessons), and (c) allostatic load (i.e., body mass index, blood pressure, and hair cortisol concentration). At 1- and 2-year follow-ups, psychological strain and allostatic load biomarkers were reassessed. Neuroticism and perceived student disruptions at baseline emerged as the most significant risk factors regarding teachers' psychological strain two years later, while a positive core self-evaluation was the most important protective factor. Perceived support from other teachers and the school administration as well as adaptive coping styles were protective factors against allostatic load after two years. The findings suggest that teachers' psychological strain and allostatic load do not primarily originate from objective classroom conditions but are attributable to teachers' idiosyncratic perception of this environment through the lens of personality and coping strategies.

Cord Blood Insulin Concentration and Hypertension Among Children and Adolescents Enrolled in a US Racially Diverse Birth Cohort

BACKGROUND

Although insulin resistance is closely related to hypertension, the debate continues as to whether insulin resistance is a cause or a consequence of hypertension. This study investigated the associations of cord blood insulin concentration with blood pressure (BP) and hypertension in childhood and adolescence.

METHODS

This study included 951 children enrolled from 1998 to 2012 and followed from birth onwards at the Boston Medical Center, Boston, MA. Cord blood insulin concentration was measured using a sandwich immunoassay. Hypertension in childhood and adolescence was defined based on the 2017 American Academy of Pediatrics Clinical Practice Guidelines.

RESULTS

The median (interquartile range) for cord blood insulin concentration was 12.1 (7.2-19.0) µIU/mL. The age range of BP measurements was 3 to 18 years (median, 10.6 years). Cord blood insulin concentration was positively associated with systolic and diastolic BP as well as the risk of hypertension at age 3 to 18 years. Compared with the lowest tertile of cord blood insulin concentration, the top tertile insulin concentration was associated with a 5.18 (95% CI, 1.97-8.39) percentile increase in systolic BP, 4.29 (95% CI, 1.74-6.84) percentile increase in diastolic BP, and 1.62-fold (95% CI, 1.27-2.08) higher risk of hypertension. The association between insulin and hypertension was stronger among children born preterm (P for interaction=0.048). Furthermore, preterm birth and childhood overweight or obesity enhanced the associations.

CONCLUSIONS

Our results suggest that elevated insulin concentration at birth plays a critical role in the early life origins of hypertension and support the hypothesis implicating insulin resistance in the etiology of hypertension.

Clinical usability of morning surge blood pressure for predicting future hypertension in a young population

Objective    Early diagnosis of hypertension (HT) is a critical issue for physicians. This study was conducted to determine if morning surge blood pressure (MSBP) could be used to predict future HT. The study also examined which demographic data in a regression model might help to detect future HT without any invasive procedure.Material and methods    A young population between 18 and 40 yrs of age was included in the study. MSBP and demographic data were used to determine an optimal model for predicting future HT by using Bayesian information criteria and binary logistic regression.Results    1321 patients with 24 hr ambulatory blood pressure monitoring were included in this study. The odds ratio of 10 units of increase in diastolic MSBP was 1.173511 in the model, which indicates that a 10 mmHg increase in diastolic MSBP increases the odds of future HT in the patient by 17.4 %. The odds ratio of age was 1.096365, meaning that at each age above 18 yrs, the patients' odds of future HT rise by 9.6 %. The odds ratios for gender (male) and previous HT were 1.656986 and 3.336759, respectively. The odds of future HT in males were 65 % higher than for females, and a history of HT implies that the odds of future HT were higher by 230 %.Conclusion    Diastolic MSBP can be used to predict HT in young individuals. In addition, age, male gender, and previous HT add more predictive power to diastolic MSBP. This statistically significant, predictive model could be useful in lessening or preventing future HT.

High blood pressure in children and adolescents: current perspectives and strategies to improve future kidney and cardiovascular health

Hypertension is one of the most common causes of preventable death worldwide. The prevalence of pediatric hypertension has increased significantly in recent decades. The cause of this is likely multifactorial, related to increasing childhood obesity, high dietary sodium intake, sedentary lifestyles, perinatal factors, familial aggregation, socioeconomic factors, and ethnic blood pressure (BP) differences. Pediatric hypertension represents a major public health threat. Uncontrolled pediatric hypertension is associated with subclinical cardiovascular disease and adult-onset hypertension. In children with chronic kidney disease (CKD), hypertension is also a strong risk factor for progression to kidney failure. Despite these risks, current rates of pediatric BP screening, hypertension detection, treatment, and control remain suboptimal. Contributing to these shortcomings are the challenges of accurately measuring pediatric BP, limited access to validated pediatric equipment and hypertension specialists, complex interpretation of pediatric BP measurements, problematic normative BP data, and conflicting society guidelines for pediatric hypertension. To date, limited pediatric hypertension research has been conducted to help address these challenges. However, there are several promising signs in the field of pediatric hypertension. There is greater attention being drawn on the cardiovascular risks of pediatric hypertension, more emphasis on the need for childhood BP screening and management, new public health initiatives being implemented, and increasing research interest and funding. This article summarizes what is currently known about pediatric hypertension, the existing knowledge-practice gaps, and ongoing research aimed at improving future kidney and cardiovascular health.

Biomarkers of high salt intake

High salt intake is associated with hypertension, which is a leading modifiable risk factor for cardiovascular disease (CVD) and chronic kidney disease (CKD). International Guidelines recommend a large reduction in the consumption of sodium to reduce blood pressure, organ damage, and mortality. In its early stages, the symptoms of CKD are generally not apparent. CKD proceeds in a "silent" manner, necessitating the need for urinary biomarkers to detect kidney damage at an early stage. Since traditional renal biomarkers, such as serum creatinine, are not sufficiently sensitive, difficulties are associated with detecting kidney damage induced by a high salt intake, particularly in normotensive individuals. Several new biomarkers for renal tubular damage, such as neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), vanin-1, liver-type fatty acid-binding protein (L-FABP), and monocyte chemotactic protein-1 (MCP-1), have recently been identified. However, few studies have investigated early biomarkers for CKD progression associated with a high salt diet. This chapter provides insights into novel biomarkers for CKD in normo- and hypertensive individuals with a high salt intake. Recent studies using spontaneously hypertensive rats (SHR) and normotensive Wistar Kyoto rats (WKY) fed a high salt diet identified urinary vanin-1 and NGAL as early biomarkers for renal tubular damage in SHR and WKY, whereas urinary KIM-1 was a useful biomarker for salt-induced renal injury in SHR only. Clinical studies are needed to confirm these findings.

Association of Placental Pathology With Childhood Blood Pressure Among Children Born Preterm

BACKGROUND

The in utero pathologies underlying the link between preterm birth and offspring high blood pressure (BP) are still unknown. We investigated the prospective associations of placental histopathological findings with childhood BP among children born preterm.

METHODS

Our study sample included 546 mother-child pairs with preterm birth (before 37 weeks gestation) enrolled from 1999 to 2013 at the Boston Medical Center. Early preterm birth was defined as gestational age between 23 and 34 weeks. We histologically classified maternal placental pathology using the latest recommended categories: no placental complications, histologic chorioamnionitis, maternal vascular malperfusion, and other placental complications. We calculated age-, sex-, and height-specific systolic BP (SBP) percentiles for children using the 2017 American Academy of Pediatrics Clinical Practice Guideline. We used linear regression models with generalized estimating equations to examine the associations.

RESULTS

The mean (standard deviation (SD)) postnatal follow-up of the study children was 9.29 (4.1) years. After adjusting for potential confounders, histologic chorioamnionitis was associated with a 5.42 percentile higher childhood SBP (95% confidence interval: 0.32, 10.52) compared with no placental pathologic findings. This association was stronger among early preterm children. Maternal vascular malperfusion was associated with a 8.44 percentile higher childhood SBP among early preterm children (95% confidence interval: 1.54, 15.34) but the association was attenuated (6.25, 95% confidence interval: -0.76, 13.26) after additional adjustment for child standardized birthweight, a potential mediator of the association.

CONCLUSIONS

These findings suggest that among children born preterm, especially those born early preterm, both placental histologic chorioamnionitis and vascular malperfusion may help to differentiate a child's risk of high BP.

Long-term blood pressure trajectories and associations with age and body mass index among urban women in South Africa

BACKGROUND

Blood pressure (BP) is known to increase inevitably with age. Understanding the different ages at which great gains could be achieved for intervention to prevent and control BP would be of public health importance.

METHODS

Data collected between 2003 and 2014 from 1 969 women aged 22 to 89 years were used in this study. Growth curve models were fitted to describe intra- and inter-individual trajectories. For BP tracking, the intra-class correlation coefficient (ICC) was used to measure dependency of observations from the same individual.

RESULTS

Four patterns were identified: a slow decrease in BP with age before 30 years; a period of gradual increase in midlife up to 60 years; a flattening and slightly declining trend; and another increase in BP in advanced age. These phases persisted but at slightly lower levels after adjustment for body mass index. Three groups of increasing trajectories were identified. The respective number (%) in the low, medium and highly elevated BP groups were 1 386 (70.4%), 482 (24.5%) and 101 (5.1%) for systolic BP; and 1 167 (59.3%), 709 (36.0%) and 93 (4.7%) for diastolic BP. The ICC was strong at 0.71 and 0.79 for systolic and diastolic BP, respectively.

CONCLUSIONS

These results show that BP preventative and control measures early in life would be beneficial for control later in life, and since increase in body mass index may worsen hypertension, it should be prevented early and independently.

A Nonlinear Relation Between Maternal Red Blood Cell Manganese Concentrations and Child Blood Pressure at Age 6-12 y: A Prospective Birth Cohort Study

BACKGROUND

Although manganese (Mn) is an essential trace element and a common component of most multivitamins on the market, an adverse effect on blood pressure (BP) has been reported in adults. In addition, the longitudinal relation between prenatal Mn status and childhood BP is still unknown.

OBJECTIVE

This study investigated the association between prenatal Mn concentrations and risk of elevated BP at ages 3-12 y.

METHOD

The analyses included 1268 mother-child dyads who were enrolled at birth and followed prospectively at the Boston Medical Center. Maternal RBC Mn concentrations were measured by inductively coupled plasma mass spectrometry, using RBCs collected within 1-3 d after delivery (reflecting late-pregnancy Mn exposure). Child elevated BP was defined as systolic or diastolic BP ≥90th percentile for a given age, sex and height. Multivariate logistic regression models were conducted. Path analysis was applied to mediation estimation.

RESULTS

The median (IQR) maternal RBC Mn concentration was 37.5 (29.2-48.5) μg/L. The rate of child elevated BP at ages 3-12 y was 25%. Both the lowest and highest quartiles of maternal RBC Mn concentrations were associated with higher risk of elevated BP among children aged 6-12 y (OR: 1.52; 95% CI: 1.04, 2.21 and OR: 1.65; 95% CI: 1.13, 2.40, respectively) compared with those in the second and third quartiles. Gestational age and fetal growth mediated the association between low maternal RBC Mn (first quartile) and child elevated BP, explaining 25% of the association, but not for high (fourth quartile) maternal RBC Mn concentrations. No association was found between maternal RBC Mn concentrations and BP among children aged 3-5 y.

CONCLUSION

We found a nonlinear association between maternal RBC Mn concentrations and elevated BP among children aged 6-12 y from a high-risk, predominantly minority population. Our findings warrant further investigation.

Impact of Pediatric Obesity on Diurnal Blood Pressure Assessment and Cardiovascular Risk Markers

Background: The prevalence of hypertension is increasing particularly among obese children and adolescents. Obese children and adolescents with hypertension are likely to remain hypertensive as they reach adulthood and hypertension is linked to an increased risk for cardiovascular disease. Twenty-four-hour ambulatory blood pressure monitoring (ABPM) has become one of the most important tools in diagnosing hypertension in children and adolescents and circadian patterns of blood pressure may be important disease-risk predictors. Methods: A retrospective chart review was conducted in patients aged 6-21 years who underwent 24-h ABPM at Kentucky Children's Hospital (KCH) from August 2012 through June 2017. Exclusion criteria included conditions that could affect blood pressure including chronic kidney disease and other renal abnormalities, congenital heart disease, cancer, and thyroid disease. Subjects were categorized by body mass index into normal (below 85th percentile), overweight (85th-95th percentile), stage I obesity (95th-119th percentile), stage II obesity (120th-139th) and stage III obesity (>140th). Non-dipping was defined as a nocturnal BP reduction of <10%. Results: Two hundred and sixty-three patients (156 male patients) were included in the analysis, of whom 70 were normal weight, 33 overweight, 55 stage I obesity, 53 stage II, and 52 stage III obesity. Although there was no significant difference between normal weight and obese groups for prevalence of hypertension, there was a greater prevalence of SBP non-dipping in obese patients as BMI increased (p = 0.008). Furthermore, non-dippers had a significantly elevated LVMI as well as abnormal lab values for uric acid, blood lipid panel, creatinine, and TSH (p < 0.05). Conclusions: These findings demonstrate that obese children and adolescents constitute a large proportion of hypertensive children and adolescents and the severity of pediatric obesity is associated with nocturnal BP non-dipping. Additionally, obesity in children is linked to several cardiovascular risk factors including left ventricular hypertrophy, dyslipidemia, and elevated uric acid levels. Further studies utilizing ABPM measures on risk stratification in this very high-risk population are warranted.

Pediatric hypertension: an updated review

Globally hypertension in adults is among the leading preventable cause of premature death, where a graded association from the childhood hypertension is well recognised. With the concurrent rise in obesity and pediatric hypertension (HTN) during the past decade in developed countries, a parallel trend is emerging in developing countries that has a potential for exponential rise in cardiovascular, cerebrovascular and renal tragedies. A cumulative incidence of pediatric HTN in China and India is 50–70 and 23% respectively, is quite disturbing. New guidelines for the detection, evaluation and management of hypertension in children and adolescents published in 2017, where a jump in prevalence of pediatric HTN is observed, rings a call to address this under-attended burning problem; for which a review in pediatric hypertension and its management is warranted.

Availability of Lower-Sodium School Lunches and the Association with Selection and Consumption among Elementary and Middle School Students

BACKGROUND

During 2010, the US Department of Agriculture updated the school meals standards, including three progressively decreasing sodium targets. The Target 1 standards went into effect in 2014, but during 2018, the US Department of Agriculture delayed the Target 2 standards until 2024 and eliminated the Target 3 standards citing concerns regarding the availability and acceptability of lower-sodium foods. In addition, there are currently no sugar standards, and it is unknown whether sugar is substituted for salt in lower-sodium school foods.

OBJECTIVE

To examine the availability, selection, and consumption of school lunches already in alignment with the Target 2 and 3 sodium levels and the association between sodium and sugar.

DESIGN

An observational cafeteria-based study conducted during fall 2018.

PARTICIPANTS AND SETTING

Students (n = 1985) in grades three through eight attending 13 elementary/kindergarten through eighth-grade schools in a large, urban school district in New England.

MAIN OUTCOME MEASURES

Availability, selection, and consumption were examined using plate waste methodology.

STATISTICAL ANALYSES PERFORMED

Mixed-model analysis of variance accounting for student demographic characteristics with schools/students as a random effect (students nested within schools) were used to examine differences in availability, selection, and consumption. Linear regression was used to examine the association between sodium and sugar in the school foods.

RESULTS

The majority of meals selected (87%) and consumed (98%) were already in alignment with the Target 2 standards. There were significant inverse associations between sodium levels and consumption; each 100-mg increase in sodium was associated with a decrease in consumption by 2% for entrées (P = 0.002) and 5% for vegetables (P = 0.01). When examining the association between sodium and sugar, each 10-mg reduction in sodium was associated with 1-g increase in sugar among entrées (P < 0.0001), whereas there was a significant positive association between sodium and sugar with vegetables and condiments.

CONCLUSIONS

This study provides some evidence that schools may already have the ability to provide lower-sodium meals that are acceptable to students, and therefore the recent rollbacks to the sodium standards may be unwarranted. Study findings suggest that the US Department of Agriculture should take under consideration policies that would limit added sugar for school meals as sugar may be substituted for salt.

Genetic Risk Scores for Complex Disease Traits in Youth

BACKGROUND

For most disease-related traits the magnitude of the contribution of genetic factors in adolescents remains unclear.

METHODS

Twenty continuous traits related to anthropometry, cardiovascular and renal function, metabolism, and inflammation were selected from the ongoing prospective Tracking Adolescents' Individual Lives Survey cohort in the Netherlands with measurements of up to 5 waves from age 11 to 22 years (n=1354, 47.6% males) and all traits available at the third wave (mean age [SD]=16.22 [0.66]). For each trait, unweighted and weighted genetic risk scores (GRSs) were generated based on significantly associated single nucleotide polymorphisms identified from literature. The variance explained by the GRSs in adolescents were estimated by linear regression after adjustment for covariates.

RESULTS

Except for ALT (alanine transaminase), all GRSs were significantly associated with their traits. The trait variance explained by the GRSs was highest for lipoprotein[a] (39.59%) and varied between 0.09% (ALT) and 18.49% (LDL [low-density lipoprotein]) for the other traits. For most traits, the variances explained in adolescents were comparable with or slightly smaller than those in adults. Significant increases of trait levels (except ALT) and increased risks for overweight/obesity (odds ratio, 6.41 [95% CI, 2.95-15.56]) and hypertension (odds ratio, 2.86 [95% CI, 1.39-6.17]) were found in individuals in the top GRS decile compared with those at the bottom decile.

CONCLUSIONS

Variances explained by adult-based GRSs for disease-related traits in adolescents, although still relatively modest, were comparable with or slightly smaller than in adults offering promise for improved risk prediction at early ages.

Recommendations for exercise and screening for safe athletic participation in hypertensive youth

Physical activity is an important component of ideal cardiovascular health. Current guidelines recommend that youth with hypertension participate in competitive sports once hypertensive target organ effects and risks have been assessed and that children with hypertension receive treatment to lower BP below stage 2 thresholds (e.g., < 140/90 mmHg or < 95th percentile + 12 mmHg) before participating in competitive sports. Despite these recommendations, pediatricians and pediatric subspecialists continue to struggle with how best to counsel their patients regarding appropriate forms of physical activity, the impact of exercise on blood pressure, and how best to screen for cardiovascular conditions that place youth at risk for sudden cardiac death. This review provides a summary of our current knowledge regarding the safety and utility of exercise in the management of high blood pressure in youth. We review determinants of blood pressure during exercise, the impact of blood pressure on cardiovascular health and structure, mechanisms for assessing cardiometabolic fitness (e.g., exercise stress test), contraindications to athletic participation, and how best to plan for athletic participation among hypertensive youth. Greater knowledge in these areas may offer clarity to providers faced with the challenge of prescribing exercise recommendations for hypertensive youth.

Relation of Blood Pressure in Childhood to Self-Reported Hypertension in Adulthood

Blood pressure (BP) tracking (maintaining a BP percentile) across life is not well defined but is important in predicting which children will become hypertensive adults. We computed BP tracking in subjects with BP measured in childhood and adulthood and performed logistic regression to determine the ability of childhood BP to predict adult hypertension (N=5035, 46.7 years, 74.2% white, 17.7% black; 39.6% male). Prevalence of hypertension was 29%. Correlations between systolic BP for child and adolescent were r=0.48; for adolescent and young adult were r=0.40, and for child and young adult were r=0.24 (all P<0.0001). Participants self-reporting adult hypertension were less likely to be white (38.7% black, 27.6% white, 20.9% other; P<0.0001) and female (26.4% females, 32.9% male, P<0.0001). Participants with adult hypertension were more likely to have higher BP and adiposity by age 10 years and abnormal lipids and glucose by age 16 years. There was a graded increase in the frequency of self-reported adult hypertension across the BP change groups, even within the persistently normotensive group (X²<0.0001) from 19% in children with a systolic BP% persistently below the median to 80% for individuals with elevated BP in both childhood and adolescence. Although our precision to predict which individual child is at risk of adult BP-related cardiovascular disease is weak, an increase in systolic BP and body mass index percentile from childhood to adolescence should signal a need for lifestyle intervention to prevent future sustained hypertension-related cardiovascular disease.

Total, insoluble, and soluble dietary fiber intake and insulin resistance and blood pressure in adolescents

BACKGROUND/OBJECTIVES

To evaluate sex and race differences in fiber intakes, which are understudied in adolescents, and to investigate whether low insoluble and soluble fiber intakes would be associated with higher risk for insulin resistance and blood pressure (BP).

SUBJECTS/METHODS

A total of 754 black and white adolescents, 14 to 18 years old (49.2% blacks; 50.3% female), were previously recruited in Augusta, Georgia, USA, between 2001 and 2005. Diet was assessed with four to seven independent 24 h dietary recalls.

RESULTS

The average daily consumption of total, insoluble, and soluble fiber were 10.9, 6.7, and 4.0 g, respectively. Only two adolescents met their daily fiber intake recommendation. Adjusted multiple linear regressions revealed that increasing dietary fiber intake from current averages to recommendation levels (12 g to 38 g in the male and 9.9 g to 25 g in the female) were associated with predicted decreases of 5.4 and 3.0 mg/dL fasting glucose, 7.0 and 5.0 mg/dL fasting insulin, 1.6 and 1.1 HOMA-IR, 6.3 and 3.7 mm Hg SBP, and 5.2 and 3.0 mm Hg DBP in the males and females, respectively (all p < 0.05). Furthermore, both insoluble and soluble fiber intakes were inversely associated with fasting insulin and HOMA-IR (p < 0.05), whereas only soluble fiber intake was found to be associated with BP (p < 0.05).

CONCLUSIONS

Fiber consumption in adolescents is far below daily-recommended levels across all sex and race groups. Lower fiber intake of all types is associated with higher insulin level. Fiber Intake at recommendation levels may be associated with significant cardiometabolic benefits.

Vitamin D Trajectories From Birth to Early Childhood and Elevated Systolic Blood Pressure During Childhood and Adolescence

Vitamin D deficiency is associated with hypertension in adults. It is unknown to what degree vitamin D status in early life can affect blood pressure (BP) a decade later. This study investigated the effect of vitamin D trajectory through early life on systolic BP (SBP) in childhood. This is a prospective birth cohort study of 775 children enrolled from 2005 to 2012 and followed prospectively up to age 18 years at the Boston Medical Center, Boston, MA. Persistent low vitamin D status is defined as plasma 25(OH)D <11 ng/mL at birth and <25 ng/mL in early childhood. Elevated SBP is defined as SBP ≥75th percentile. Low vitamin D status at birth was associated with higher risk of elevated SBP at ages 3 to 18 years: odds ratio, 1.38; (95% CI, 1.01-1.87) compared to those with sufficient vitamin D. Low vitamin D status in early childhood was associated with a 1.59-fold (95% CI, 1.02-2.46) higher risk of elevated SBP at age 6 to 18 years. Persistent low vitamin D status from birth to early childhood was associated with higher risk of elevated SBP (odds ratio, 2.04; [95% CI, 1.13-3.67]) at ages 3 to 18 years. These results suggest that low vitamin D status and trajectory in early life were associated with increased risk of elevated SBP during childhood and adolescence. Our findings will help inform future clinical and public health strategies for vitamin D screening and supplementation in pregnancy and childhood to prevent or reduce risk of elevated BP across the lifespan and generations.

Hypertension in Children and Adolescents

Hypertension is a growing problem in children and adolescents, with primary hypertension becoming the most common etiology. In addition to demonstrating that high blood pressure in children and young adults is likely to remain elevated into adulthood, this review (1) addresses important aspects of measuring blood pressure in children and adolescents, (2) defines elevated blood pressure and hypertension in this age group, (3) describes the initial evaluation and workup of abnormally high blood pressure, and (4) introduces treatment strategies for youth with sustained hypertension.

Association between hypertension in adolescents and the health risk factors of their parents: an epidemiological family study

Hypertension in adolescence may be a predictor of cardiovascular problems in adulthood. Therefore, verification of the factors associated with this condition in adolescence is important. The aim of this study was to analyze the relationship between hypertension in adolescents with hypertension and the sociodemographic characteristics and lifestyle of their parents. This study was conducted on 1231 adolescents, 1202 mothers, and 871 fathers. The blood pressure of the adolescents was measured with an oscillometric device. Details of parental hypertension, sociodemographic characteristics, and lifestyle were obtained by self-report. The prevalence of hypertension was higher among adolescents with older fathers and older mothers, with both parents reporting hypertension and with mothers who were overweight. In multivariable analysis, adolescents with older mothers (OR = 2.36; 95% confidence interval [CI] = 1.12-4.98), hypertensive mothers (OR = 2.22 [95% CI = 1.26-3.89]), and hypertensive fathers (OR = 1.70 [95% CI = 1.03-2.81]) were more likely to have hypertension. In the analysis that considered clusters of health risk factors, higher risks of hypertension were observed in adolescents whose mothers had four or more aggregated risk factors (OR = 2.53 [95% CI = 1.11-5.74]). In conclusion, there was a relationship between hypertension in adolescents and hypertension in their parents. However, an association between hypertension in adolescents and parental age and clusters of health risk factors was only observed for their mothers.

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.

Joint effect of maternal plasma homocysteine and prepregnancy obesity on child blood pressure: a prospective birth cohort study

BACKGROUND/OBJECTIVES

Elevated homocysteine (Hcy) is a known cardiovascular risk factor. However, its role in intergenerational cardiometabolic risk is unknown. We hypothesized that maternal elevated Hcy can act alone or in combination with maternal prepregnancy obesity to increase child systolic blood pressure (SBP).

METHODS

This study included 1279 mother-child pairs who were enrolled at birth and followed prospectively up to age 9 years from 2003 to 2014 at the Boston Medical Center. Child SBP percentile was calculated according to US reference data and elevated SBP was defined as SBP⩾75th percentile.

RESULTS

A U-shaped relationship between maternal Hcy and her child SBP was observed. The risk for child elevated SBP was higher among those in the lowest quartile (Q1, odds ratio (OR): 1.27; 95% confidence interval (CI): 0.94-1.72), and highest quartile (Q4, OR: 1.34; 95% CI: 1.00-1.81) as compared with those in quartiles 2 and 3. The highest risk of child elevated SBP was found among children born to obese mothers with Hcy in Q4 (OR: 2.22; 95%CI: 1.35-3.64), compared with children of non-obese mothers with Hcy in Q2-Q3. This association was independent from maternal folate and vitamin B12 status, and was not mediated by gestational age or size at birth.

CONCLUSIONS

In this prospective birth cohort, we observed a U-shaped association between maternal Hcy levels and child elevated SBP. Maternal high Hcy (Q4) and prepregnancy obesity jointly increased the risk of child elevated SBP by more than two-fold.

Blood pressure in young adulthood and residential greenness in the early-life environment of twins

BACKGROUND

Previous research shows that, besides risk factors in adult life, the early-life environment can influence blood pressure and hypertension in adults. However, the effects of residential traffic exposure and residential greenness in the early-life on blood pressure in young adulthood are currently unknown.

METHODS

Ambulatory (24-h) blood pressures of 278 twins (132 pairs) of the East Flanders Prospective Twins Study were obtained at the age of 18 to 25 years. Prenatal and adulthood residential addresses were geocoded and used to assign prenatal and postnatal traffic and greenness indicators. Mixed modelling was performed to investigate blood pressure in association with greenness while adjusting for potential confounding factors.

RESULTS

Night-time systolic blood pressure was inversely associated with greenness at the residential address in twins living at the same address their entire life (non-movers, n = 97, 34.9%). An interquartile increase in residential greenness exposure (1000 m radius) was associated with a 3.59 mmHg (95% CI: -6.0 to -1.23; p = 0.005) lower adult night systolic blood pressure. Among twins who were living at a different address than their birth address at time of the measurement (n = 181, 65.1%), night-time blood pressure was inversely associated with residential surrounding greenness at adult age as well as with residential greenness in early-life. However after additional adjustment for residential greenness exposure in adulthood, only residential greenness exposure in early-life was significantly associated with night systolic blood pressure. While no significant effect of adult residential greenness with adult blood pressure was observed, while accounting for the early-life greenness exposure.

CONCLUSIONS

Lower residential greenness in the early-life environment was independently associated with a higher adult blood pressure. This indicates that residential greenness has persistent effects on blood pressure.

Association of Maternal Plasma Folate and Cardiometabolic Risk Factors in Pregnancy with Elevated Blood Pressure of Offspring in Childhood

BACKGROUND

The prevalence of childhood elevated blood pressure (BP) has increased in the United States, particularly among African Americans. The influence of maternal plasma folate levels, alone or in combination with maternal cardiometabolic risk factors (hypertensive disorders, diabetes, and prepregnancy obesity), on child systolic BP (SBP) has not been examined in a prospective birth cohort. We hypothesize that adequate maternal folate levels can reduce the risk of elevated SBP in children born to mothers with cardiometabolic risk factors.

METHODS

This study included 1,290 mother-child dyads (875 African Americans (67.8%)) recruited at birth and followed prospectively up to age 9 years from 2003 to 2014 at the Boston Medical Center. Child SBP percentile was calculated according to US reference data and elevated SBP was defined as SBP ≥75th percentile.

RESULTS

Maternal folate levels, overall, were not associated with child SBP. However, we found a significant multiplicative interaction between maternal cardiometabolic risk factors and maternal folate levels (Pinteraction = 0.015) on childhood elevated SBP. Among children born to mothers with any cardiometabolic risk factors, those whose mothers had folate levels above (vs. below) the median had 40% lower odds of elevated childhood SBP (odds ratio = 0.60, 95% confidence interval: 0.40-0.90). The associations did not differ appreciably in analyses restricted to African Americans, and they were not explained by gestational age, size at birth, prenatal folate intake, or breastfeeding.

CONCLUSIONS

Findings from our urban minority birth cohort suggest that higher levels of maternal folate may help counteract the adverse associations of maternal cardiometabolic risk factors on child SBP.

Psychiatric correlates of blood pressure variability in the elderly: The Three City cohort study

BACKGROUND

The modifiable factors associated with blood pressure variability (BPV) are still being established and their clinical relevance is poorly understood. Generalized anxiety disorder (GAD) and depression have been implicated with higher BPV in the short term (e.g. hours, days) however their effects on BPV over longer periods are unknown.

METHODS

In a prospective cohort study, 1454 elderly participants (age 78.5±3.78years, 59% women) underwent structured interview for GAD and major depression. Participants performed home blood pressure monitoring (HBPM) over 3 consecutive days and underwent serial clinic BP measures on 4 separate follow-ups over an 8year period. Systolic and diastolic BPV was calculated using the coefficient of variation (CV) and standard deviation method. Generalized linear models assessed the association between GAD and depression with BPV over an 8year period.

RESULTS

GAD was associated with significantly increased systolic BPV over 8years in age, sex and mean systolic BP (β=0.25, SE=0.09; p=0.007) and fully adjusted models (β=0.23, SE=0.10; p=0.017). BPV from HBPM was strongly associated with 8year systolic BPV in age-sex (β=3.10, SE=0.82; p<0.001) and fully adjusted models (β=3.09, SE=0.84; p<0.001). The association between GAD and longer term BPV was consistent when analyzing morning and evening HBPM measures of BPV. There was no association between diastolic BPV over 8years with GAD or depression.

CONCLUSIONS

GAD but not depression was associated with increased systolic BPV over an 8year period controlling for HBPM. GAD has clinical relevance for control of systolic BPV in elderly participants.

Pulse wave velocity in elastic and muscular arteries: tracking stability and association with anthropometric and hemodynamic measurements

Pulse wave velocity (PWV) has been used as a measurement for arterial stiffness, a predictor of cardiovascular risk. Tracking describes the stability of a measurement over time. The purpose of this study was to evaluate the tracking stability of carotid-femoral (cfPWV), carotid-radial (crPWV) and carotid-distal (cdPWV) PWV in young adults and their associations with anthropometric and hemodynamic measurements. cfPWV, crPWV and cdPWV were measured by tonometric (SphygmoCor) technique in 531 subjects (aged 23.7±4.9 with 42.9% African Americans and 49.9% females). Out of these subjects, 142 subjects had all these 3 PWV measurements evaluated again during their next visit with an average follow-up time of 2 years. In the tracking analysis on the data from the 142 subjects, cfPWV displayed moderate to relatively high tracking ability (r=0.61, P<0.001), whereas crPWV and cdPWV only displayed low to moderate tracking coefficients (r=0.29 and r=0.36 respectively, P<0.001). In the association test on the data from the 531 subjects, all three PWV measurements showed significant correlations with age and obesity related measurements. cfPWV displayed stronger correlations with these parameters. In addition, all three PWVs showed significant correlations with systolic blood pressure, diastolic blood pressure, mean arterial pressure and pulse pressure with the exception that no correlation existed between crPWV and pulse pressure. The higher tracking ability of cfPWV and its higher association with obesity related measurements highlights the importance of using cfPWV compared with crPWV and cdPWV for research and clinical settings.

US consumer attitudes toward sodium in baby and toddler foods

Dietary data from a nationally representative survey indicate about 80% of US toddlers aged 1-3 years consume too much dietary sodium, which can influence their preference for salty foods in later life. Information on consumer attitudes can inform strategies to reduce sodium in baby and toddler foods. Data were obtained from a 2012 online survey sent to a sample of 11636 US adults aged ≥18 years enrolled in a national probability-based consumer panel; 6378 completed the survey and had non-missing responses to the question of interest, "It is important for baby and toddler foods to be low in sodium." Prevalence of agreement was estimated. Logistic regression was used to describe associations of respondent characteristics with agreement. The majority of respondents were non-Hispanic white and had a household income ≥$60,000. About 7 in 10 (68%, 95% CI: 66%-70%) respondents agreed it is important for baby or toddler foods to be low in sodium. More than 6 of 10 respondents in most subgroups agreed. Among parents with a child currently aged <2 years (N = 390), 82% agreed (95% CI: 77%-87%); the highest agreement included parents who thought sodium was very harmful to their own health (92%, 95% CI: 85%-99%) or who were watching/reducing their own sodium intake (95%, 95% CI: 90%-100%). After adjusting for sex, age, race-ethnicity, agreement was most strongly associated with being a parent of a child <2 years, thinking sodium was harmful, and watching/reducing sodium intake (adjusted odds ratios ≥ 2.5, 95% CI's ≠1.0). The majority of respondents including most parents agreed it is important for baby and toddler foods to be low in sodium, suggesting wide consumer support for strategies to lower sodium in these foods.

Accuracy of Blood Pressure-to-Height Ratio to Define Elevated Blood Pressure in Children and Adolescents: The CASPIAN-IV Study

The aim of this study was to propose a simple practical diagnostic criterion for pre-hypertension (pre-HTN) and hypertension (HTN) in the pediatric age group. This study was conducted on a nationally representative sample of 14,880 students, aged 6-18 years. HTN and pre-HTN were defined as systolic blood pressure (SBP) and/or diastolic blood pressure (DBP) ≥ 95 and 90-95th percentile for age, gender, and height, respectively. By using the area under the curve (AUC) of the receiver operator characteristic curves, we estimated the diagnostic accuracy of two indexes of SBP-to-height ratio (SBPHR) and DBP-to-height (DBPHR) to define pre-HTN and HTN. Overall, SBPHR performed relatively well in classifying subjects to HTN (AUC 0.80-0.85) and pre-HTN (AUC 0.84-0.90). Likewise, DBPHR performed relatively well in classifying subjects to HTN (AUC 0.90-0.97) and pre-HTN (AUC 0.70-0.83). Two indexes of SBPHR and DBPHR are considered as valid, simple, inexpensive, and accurate tools to diagnose pre-HTN and HTN in pediatric age group.

Sodium and sugar in complementary infant and toddler foods sold in the United States

OBJECTIVES

To evaluate the sodium and sugar content of US commercial infant and toddler foods.

METHODS

We used a 2012 nutrient database of 1074 US infant and toddler foods and drinks developed from a commercial database, manufacturer Web sites, and major grocery stores. Products were categorized on the basis of their main ingredients and the US Food and Drug Administration's reference amounts customarily consumed per eating occasion (RACC). Sodium and sugar contents and presence of added sugars were determined.

RESULTS

All but 2 of the 657 infant vegetables, dinners, fruits, dry cereals, and ready-to-serve mixed grains and fruits were low sodium (≤140 mg/RACC). The majority of these foods did not contain added sugars; however, 41 of 79 infant mixed grains and fruits contained ≥1 added sugar, and 35 also contained >35% calories from sugar. Seventy-two percent of 72 toddler dinners were high in sodium content (>210 mg/RACC). Toddler dinners contained an average of 2295 mg of sodium per 1000 kcal (sodium 212 mg/100 g). Savory infant/toddler snacks (n = 34) contained an average of sodium 1382 mg/1000 kcal (sodium 486 mg/100 g); 1 was high sodium. Thirty-two percent of toddler dinners and the majority of toddler cereal bars/breakfast pastries, fruit, and infant/toddler snacks, desserts, and juices contained ≥1 added sugar.

CONCLUSIONS

Commercial toddler foods and infant or toddler snacks, desserts, and juice drinks are of potential concern due to sodium or sugar content. Pediatricians should advise parents to look carefully at labels when selecting commercial toddler foods and to limit salty snacks, sweet desserts, and juice drinks.

Cardiovascular risk factors in children after repeat doses of antenatal glucocorticoids: an RCT

BACKGROUND

Treatment of women at risk for preterm birth with repeat doses of glucocorticoids reduces neonatal morbidity but could have adverse long-term effects on cardiometabolic health in offspring. We assessed whether exposure to repeat antenatal betamethasone increased risk factors for later cardiometabolic disease in children whose mothers participated in the Australasian Collaborative Trial of Repeat Doses of Corticosteroids.

METHODS

Women were randomized to betamethasone or placebo treatment, ≥ 7 days after an initial course of glucocorticoids, repeated each week that they remained at risk for preterm birth at <32 weeks' gestation. In this follow-up study, children were assessed at 6 to 8 years' corrected age for body composition, insulin sensitivity, ambulatory blood pressure, and renal function.

RESULTS

Of 320 eligible childhood survivors, 258 were studied (81%; 123 repeat betamethasone group; 135 placebo [single course] group). Children exposed to repeat antenatal betamethasone and those exposed to placebo had similar total fat mass (geometric mean ratio 0.98, 95% confidence interval [CI] 0.78 to 1.23), minimal model insulin sensitivity (geometric mean ratio 0.89, 95% CI 0.74 to 1.08), 24-hour ambulatory blood pressure (mean difference systolic 0 mm Hg, 95% CI -2 to 2; diastolic 0 mm Hg, 95% CI -1 to 1), and estimated glomerular filtration rate (mean difference 1.2 mL/min/1.73 m(2), 95% CI -3.2 to 5.6).

CONCLUSIONS

Exposure to repeat doses of antenatal betamethasone compared with a single course of glucocorticoids does not increase risk factors for cardiometabolic disease at early school age.

Programming of cardiovascular disease across the life-course

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality, affecting both developed and developing countries. Whilst it is well recognized that our risk of CVD can be determined by the interaction between our genetics and lifestyle, this only partly explains the variability at the population level. Based on these well-known risk factors, for many years, intervention and primary prevention strategies have focused on modifying lifestyle factors in adulthood. However, research shows that our risk of CVD can be pre-determined by our early life environment and this area of research is known as the Developmental Origins of Health and Disease. The aim of this review is to evaluate our current understanding of mechanisms underlying the programming of CVD. This article is part of a special issue entitled CV Aging.

Vital signs: sodium intake among U.S. school-aged children - 2009-2010

BACKGROUND

A national health objective is to reduce average U.S. sodium intake to 2,300 mg daily to help prevent high blood pressure, a major cause of heart disease and stroke. Identifying common contributors to sodium intake among children can help reduction efforts.

METHODS

Average sodium intake, sodium consumed per calorie, and proportions of sodium from food categories, place obtained, and eating occasion were estimated among 2,266 school-aged (6–18 years) participants in What We Eat in America, the dietary intake component of the National Health and Nutrition Examination Survey, 2009–2010.

RESULTS

U.S. school-aged children consumed an estimated 3,279 mg of sodium daily with the highest total intake (3,672 mg/d) and intake per 1,000 kcal (1,681 mg) among high school–aged children. Forty-three percent of sodium came from 10 food categories: pizza, bread and rolls, cold cuts/cured meats, savory snacks, sandwiches, cheese, chicken patties/nuggets/tenders, pasta mixed dishes, Mexican mixed dishes, and soups. Sixty-five percent of sodium intake came from store foods, 13% from fast food/pizza restaurants, 5% from other restaurants, and 9% from school cafeteria foods. Among children aged 14–18 years, 16% of total sodium intake came from fast food/pizza restaurants versus 11% among those aged 6–10 years or 11–13 years (p<0.05). Among children who consumed a school meal on the day assessed, 26% of sodium intake came from school cafeteria foods. Thirty-nine percent of sodium was consumed at dinner, followed by lunch (29%), snacks (16%), and breakfast (15%).

IMPLICATIONS FOR PUBLIC HEALTH PRACTICE

Sodium intake among school-aged children is much higher than recommended. Multiple food categories, venues, meals, and snacks contribute to sodium intake among school-aged children supporting the importance of populationwide strategies to reduce sodium intake. New national nutrition standards are projected to reduce the sodium content of school meals by approximately 25%–50% by 2022. Based on this analysis, if there is no replacement from other sources, sodium intake among U.S. school-aged children will be reduced by an average of about 75–150 mg per day and about 220–440 mg on days children consume school meals.

Genetic and environmental influences on blood pressure variability: a study in twins

OBJECTIVES

Blood pressure variability (BPV) and its reduction in response to antihypertensive treatment are predictors of clinical outcomes; however, little is known about its heritability. In this study, we examined the relative influence of genetic and environmental sources of variance of BPV and the extent to which it may depend on race or sex in young twins.

METHODS

Twins were enrolled from two studies. One study included 703 white twins (308 pairs and 87 singletons) aged 18-34 years, whereas another study included 242 white twins (108 pairs and 26 singletons) and 188 black twins (79 pairs and 30 singletons) aged 12-30 years. BPV was calculated from 24-h ambulatory blood pressure recording.

RESULTS

Twin modeling showed similar results in the separate analysis in both twin studies and in the meta-analysis. Familial aggregation was identified for SBP variability (SBPV) and DBP variability (DBPV) with genetic factors and common environmental factors together accounting for 18-40% and 23-31% of the total variance of SBPV and DBPV, respectively. Unique environmental factors were the largest contributor explaining up to 82-77% of the total variance of SBPV and DBPV. No sex or race difference in BPV variance components was observed. The results remained the same after adjustment for 24-h blood pressure levels.

CONCLUSIONS

The variance in BPV is predominantly determined by unique environment in youth and young adults, although familial aggregation due to additive genetic and/or common environment influences was also identified explaining about 25% of the variance in BPV.

Testing a capacity-load model for hypertension: disentangling early and late growth effects on childhood blood pressure in a prospective birth cohort

BACKGROUND

In 2005, it was estimated that hypertension affected 26.4% of the adult population worldwide. By 2025, it is predicted that it will affect about 60% of adults, a total of 1.56 billion. Both pre- and postnatal growth patterns have been associated with later blood pressure (BP), but in contrasting directions. These inconsistent associations of growth during different developmental periods merit elucidation. We tested a theoretical model treating birth weight as a marker of homeostatic metabolic capacity, and childhood height, lean mass and fat mass as independent indices of metabolic load. We predicted that decreased capacity and increased load would be independently associated with increased BP.

METHODS AND FINDINGS

Data from the ALSPAC cohort on growth from birth to 7 years, and body composition by dual-energy X-ray absorptiometry and BP at 9 years, were analysed (n = 6579). Data were expressed as standard deviation scores (SDS) or standardised regression residuals (SRR). BP was independently and positively associated with each of height, lean mass and fat mass. In a joint model systolic BP was positively associated with conditional weight velocity [males 0.40 (95%CI: 0.37-0.44) & females 0.44 (95%CI: 0.40-0.47) SDS/SRR], but not birth weight [0.00 (95%CI: -0.03-0.04) & 0.03 (95%CI: -0.01-0.07) SDS/SDS]. Adjusting for height, lean mass and fat mass, the association of systolic BP and conditional weight velocity attenuated [0.00(95%CI: -0.09-0.08) & -0.06(95%CI: -0.14-0.03) SDS/SRR], whereas that with birth weight became negative [-0.10 (95%CI: -0.14-0.06) & -0.09 (95%CI: -0.13-0.05) SDS/SDS]. Similar results were obtained for diastolic BP and pulse pressure.

CONCLUSIONS

Consistent with our theoretical model, high metabolic load relative to metabolic capacity is associated with increased BP. Our data demonstrate the contribution of different growth and body composition components to BP variance, and clarify the developmental aetiology of hypertension.

Pediatric ambulatory blood pressure monitoring: indications and interpretations

The prevalence of hypertension in children and adolescents is increasing, especially in obese and ethnic children. The adverse long-term effects of hypertension beginning in youth are known; therefore, it is important to identify young patients who need intervention. Unfortunately, measuring blood pressure (BP) is difficult due to the variety of techniques available and innate biologic variation in BP levels. Ambulatory BP monitoring may overcome some of the challenges clinicians face when attempting to categorize a young patient's BP levels. In this article, the authors review the use of ambulatory BP monitoring in pediatrics, discuss interpretation of ambulatory BP monitoring, and discuss gaps in knowledge in usage of this technique in the management of pediatric hypertension.

Efficacy and safety of valsartan compared to enalapril in hypertensive children: a 12-week, randomized, double-blind, parallel-group study

OBJECTIVE

This study compares efficacy and safety of valsartan with enalapril in hypertensive children aged 6-17 years.

METHOD

This was a 12-week, randomized, double-blind, parallel-group, active-controlled study. After a single-blind placebo run-in period (4-28 days), patients with mean sitting systolic blood pressure (BP) (MSSBP) at least 95th percentile for age, gender, and height were randomized to receive half the assigned dose for first week, and force-titrated to full dose for 11 weeks (≥18 to <35 kg - valsartan: 80 mg, enalapril: 10 mg; ≥35 to <80 kg - valsartan: 160 mg, enalapril: 20 mg; ≥80 to ≤160 kg - valsartan: 320 mg, enalapril: 40 mg). The primary efficacy variable was changed from baseline in MSSBP to show noninferiority of valsartan to enalapril. Other efficacy variables were changed from baseline in MSDBP, SBP control rate, and 24-h ambulatory BP parameters.

RESULTS

Of 300 randomized patients, 281 (94%) completed the study. At week 12, MSSBP reductions were similar for valsartan and enalapril (primary endpoint of noninferiority, P < 0.0001). Least square mean BP reductions from baseline of -15.4/-9.4 mmHg were observed for valsartan compared with -14.1/-8.5 mmHg for enalapril. A similar proportion of patients achieved SBP control (valsartan: 67%; enalapril: 70%). In the subset of patients who underwent ambulatory BP assessments, valsartan provided greater reductions than enalapril in mean 24-h SBP (valsartan: -9.8 mmHg, enalapril: -7.2 mmHg: P = 0.03). The overall incidence of AEs was similar (valsartan 60%, enalapril 58%) with headache, cough, and nasopharyngitis reported most frequently.

CONCLUSIONS

Valsartan and enalapril provided comparable BP reductions and effective BP control and were well tolerated in hypertensive children aged 6-17 years.

A survey of recent reports on ambulatory blood pressure monitoring

This article is a review of 25 publications on ambulatory blood pressure monitoring (ABPM) and the importance of its results in everyday clinical practice. These studies, published in 2008-2011, were selected from the Scopus database, but are also available in Pubmed. They were prepared by researchers from around the world, concerned with the problems of proper control of blood pressure (BP), and of abnormalities in the circadian pattern of BP in patients with arterial hypertension, diabetes mellitus or renal failure. In the first part of this article, I analyse publications focused on some nuances in the methodology of ABPM and recommend ways to avoid some traps, related not only to the individual patient but also to the device used and the technical staff. The next section is devoted to the advantages of ABPM as a diagnostic tool which enables clinicians to learn about patients’ BP during sleep, and emphasizes the practical implications of this information for so-called chronotherapy. This section also presents some new studies on the prognostic value of ABPM in patients with cardiovascular (CV) risk. Some recent articles on the results of various methods of pharmacological treatment of arterial hypertension in different age groups are then described. The observations presented in this article may be helpful not only for researchers interested in the chronobiology of the CV system, but also for general practitioners using ABPM.

Blood pressure to height ratios as simple, sensitive and specific diagnostic tools for adolescent (pre)hypertension in Nigeria

Background

The age-, gender-, and height-percentile requirements of the 'gold-standard' for the diagnosis of (pre)hypertension in adolescents make it time-consuming for clinicians and difficult-to-use by non-professionals. Simplified diagnostic tools are therefore needed. The use of blood pressure-to-height ratio (BPHR) - systolic BPHR (SBPHR) and diastolic BPHR (DBPHR) - has been reported in Han adolescents, but it requires validation in other racial groups. The diagnostic accuracy of SBPHR and DBPHR in a population of 1,173 Nigerian adolescents aged 11-17 years, was therefore studied.

Methods

Blood pressures were measured using standard procedures and (pre)hypertension were defined according to international recommendations. ROC curve analyses were used to assess the diagnostic accuracy of BPHR in defining (pre)hypertension in this population. Sex-specific threshold values for SBPHR and DBPHR were determined, and thereafter used to define (pre)hypertension. The sensitivity/specificity of this method was determined.

Results

The accuracies of SBPHR and DBPHR in diagnosing (pre)hypertension, in both sexes, was >92%. The optimal thresholds for diagnosing prehypertension were 0.72/0.46 in boys and 0.73/0.48 in girls; while for hypertension, they were 0.75/0.51 in boys and 0.77/0.50 in girls. The sensitivity and specificity of this method were >96%.

Conclusions

The use of BPHR is valid, simple and accurate in this population. Race-specific thresholds are however needed.

Life course trajectories of systolic blood pressure using longitudinal data from eight UK cohorts

BACKGROUND

Much of our understanding of the age-related progression of systolic blood pressure (SBP) comes from cross-sectional data, which do not directly capture within-individual change. We estimated life course trajectories of SBP using longitudinal data from seven population-based cohorts and one predominantly white collar occupational cohort, each from the United Kingdom and with data covering different but overlapping age periods.

METHODS AND FINDINGS

Data are from 30,372 individuals and comprise 102,583 SBP observations spanning from age 7 to 80+y. Multilevel models were fitted to each cohort. Four life course phases were evident in both sexes: a rapid increase in SBP coinciding with peak adolescent growth, a more gentle increase in early adulthood, a midlife acceleration beginning in the fourth decade, and a period of deceleration in late adulthood where increases in SBP slowed and SBP eventually declined. These phases were still present, although at lower levels, after adjusting for increases in body mass index though adulthood. The deceleration and decline in old age was less evident after excluding individuals who had taken antihypertensive medication. Compared to the population-based cohorts, the occupational cohort had a lower mean SBP, a shallower annual increase in midlife, and a later midlife acceleration. The maximum sex difference was found at age 26 (+8.2 mm Hg higher in men, 95% CI: 6.7, 9.8); women then experienced steeper rises and caught up by the seventh decade.

CONCLUSIONS

Our investigation shows a general pattern of SBP progression from childhood in the UK, and suggests possible differences in this pattern during adulthood between a general population and an occupational population. Please see later in the article for the Editors' Summary.

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

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

A longitudinal study of blood pressure variability in African-American and European American youth

OBJECTIVES

High blood pressure variability is increasingly used as a predictor of target-organ damage and cardiovascular events. However, little is known about blood pressure variability changes with age and its possible sociodemographic, anthropometric, and genetic moderators.

METHODS

Twenty-four-hour ambulatory blood pressure was measured up to 12 times over a 15-year period in 344 European Americans and 297 African-Americans with an average age of 14 years at the initial visit. Blood pressure variability was indexed by the weighted 24-h standard deviation of ambulatory blood pressure recordings.

RESULTS

Both systolic and diastolic blood pressure variability increased with age and ambulatory blood pressure mean values. Men had higher levels of blood pressure variability (P < 0.001) and showed steeper linear increase rates with age than women. African-Americans showed higher values of blood pressure variability (P < 0.05) than European Americans. Body mass index and waist circumference were also associated with higher blood pressure variability levels (P < 0.001). Individuals with higher father's education level showed lower blood pressure variability. In the full model which included all the above factors, ethnic difference in systolic blood pressure variability was no longer significant.

CONCLUSION

The results of the present study suggest that men and African-Americans have higher blood pressure variability than women and European Americans. Apart from these ethnicity and sex effects, blood pressure variability increases with increases in age (especially in men), ambulatory blood pressure mean values and adiposity as well as decreased socioeconomic status.

Genetic influence on blood pressure measured in the office, under laboratory stress and during real life

To determine to what extent the genetic influences on blood pressure (BP) measured in the office, under psychologically stressful conditions in the laboratory and during real life are different from each other. Office BP, BP during a video game challenge and a social stressor interview, and 24-h ambulatory BP were measured in 238 European American and 186 African American twins. BP values across the two tasks were averaged to represent stress levels. Genetic model fitting showed no ethnic or gender differences for any of the measures. The model fitting resulted in heritability estimates of 63, 75 and 71% for office, stress and 24-h systolic BP (SBP) and 59, 67 and 69% for diastolic BP (DBP), respectively. Up to 81% of the heritability of office SBP and 71% of office DBP were attributed to genes that also influenced stress BP. However, only 45% of the heritability of 24-h SBP and 49% of 24-h DBP were attributed to genes that also influence office BP. Similarly, about 39% of the heritability of 24-h SBP and 42% of 24-h DBP were attributed to genes that also influence stress BP. Substantial overlap exists between genes that influence BP measured in the office, under laboratory stress and during real life. However, significant genetic components specific to each BP measurement also exist. These findings suggest that partly different genes or sets of genes contribute to BP regulation in different conditions.

Hypertension in children: new trends and challenges

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

Tracking of serum 25-hydroxyvitamin D levels during 14 years in a population-based study and during 12 months in an intervention study

Low serum 25-hydroxyvitamin D (25(OH)D) levels are associated with risk factors for cardiovascular disease, and they also appear to predict later development of type 2 diabetes, cancer, and an increased mortality rate. These predictions are all based on a single 25(OH)D measurement, but so far there are no known reports on tracking of serum 25(OH)D levels. In the present Norwegian study, serum 25(OH)D levels were measured 1) in 2,668 subjects in the 1994 and 2008 Tromsø surveys and 2) every third month for 1 year in 94 subjects randomly assigned to placebo in a vitamin D intervention study. There was a marked seasonal variation in 25(OH)D, and, depending on the method of adjusting for season, the correlation coefficient between serum 25(OH)D measurements from 1994 and 2008 ranged from 0.42 to 0.52. In the 1-year intervention study, the correlation between baseline and 12-month values was 0.80. Apart from the effect of season, changes in weight, intake of vitamin D, and physical activity were related to change in serum 25(OH)D levels. Tracking of serum 25(OH)D appears similar to that for blood pressure and serum lipids, and it provides some support for the use of a single 25(OH)D measurement to predict future health outcomes.