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

Alteration of gut microbiota associated with hypertension in children

BACKGROUND

The association of disturbance in gut microbiota with hypertension (HTN) defined on three separate occasions among children and adolescents remains unclear. In this study, we aimed to compare the differences in gut microbiota composition and diversity between children with HTN and those with normal blood pressure (BP).

METHODS

Data and stool samples were collected from the second follow-up of a childhood cardiovascular health cohort study in 2021. 16 S ribosomal RNA gene sequencing was conducted to determine the relative abundance of microbial taxa in 51 children aged 10-14 years with HTN and 51 children with normal BP.

RESULTS

Compared with children with normal BP, those with HTN had decreased gut microbiome diversity. At the genus level, after adjusting for the false discovery rate (FDR), the proportions of several gut microbiota such as Blautia (PFDR=0.042), Coprococcus (PFDR=0.042), Eubacterium_ventriosum_group (PFDR=0.027), Christensenellaceae_R-7_group (PFDR=0.027), and norank_f__Lachnospiraceae (PFDR=0.015) significantly decreased in children with HTN compared to those with normal BP. Receiver operating characteristic analysis, net reclassification improvement (NRI) and integrated discrimination improvement (IDI) were performed and showed that the genera norank_f__Lachnospiraceae and Dorea significantly enhanced the ability of body mass index to differentiate between children with HTN and those with normal BP (area under the receiver operating characteristic curve: 0.95, 95% confidence interval 0.91-0.99; NRI > 0; IDI = 0.12, P < 0.05). Phylogenetic Investigation of Communities by Reconstruction of Unobserved States showed that the mean proportions of cofactors and vitamins metabolism pathway and the glycan anabolism pathway were higher in children with HTN.

CONCLUSIONS

Disturbances in the abundance and diversity of gut microbiota may contribute to the development of HTN in children. Gut microbiota biomarkers may be of significant importance in the early identification and diagnosis of childhood HTN.

CLINICAL TRIAL NUMBER

Not applicable.

Mediative role of body mass index in cardiorespiratory fitness-associated vascular remodeling in youth

BACKGROUND

Data on fitness-associated arterial remodeling in children is limited. We assessed the relation between cardiorespiratory fitness (CRF) and intima-media thickness (IMT), diameter, IMT:diameter-ratio (IDR), and tensile stress of the common carotid artery (CCA) in 697 healthy German schoolchildren. Further, we explored how body mass index (BMI) may influence these associations.

METHODS

We measured the vascular parameters with a high-resolution ultrasound device. We determined CRF using the FITNESSGRAM® PACER test and calculated each child's allometrically scaled peak oxygen uptake capacity (VO2peak).

RESULTS

VO2peak, reflecting CRF, showed positive direct effects on IMT (girls: p < 0.001; boys: p = 0.02) and diameter in girls (p < 0.001). Considering BMI as a mediator, higher CRF was indirectly linked to decreases in IMT (girls: p = 0.04; boys: p = 0.02) and diameter (both p < 0.001), reflecting a competitive mediation. CRF indirectly mitigated the BMI-associated decrease in IDR (both p < 0.001) and increase in tensile stress (both p < 0.001) without affecting any of these parameters directly.

CONCLUSION

CRF appears to be linked to uniform arterial remodeling with balanced hemodynamics and to further alleviate BMI-associated, potentially adverse vascular alterations, highlighting its significant role in cardiovascular health in youth.

IMPACT

Data on CRF-associated arterial remodeling in youth is limited. Higher VO2peak, reflecting higher CRF, was positively associated with IMT in girls and boys and diameter in girls. These direct effects were counteracted by the indirect BMI-mediated effect of CRF on IMT and diameter, reflecting a competitive mediation. A higher CRF indirectly mitigated the BMI-associated decrease in IDR and increase in tensile stress without directly affecting any of these parameters. Our findings indicate homogenous remodeling and balanced hemodynamics with increasing CRF-and opposite effects with increasing BMI.

Hypertension prevalence in Korean adolescents according to parental hypertension: data from the Korea National Health and Nutrition Survey

The prevalence of hypertension among children and adolescents has risen to 4% globally in recent decades, presenting a significant public health challenge due to its association with increased cardiovascular risks. Existing research on the transmission of hypertension risk between parents and offspring lacks comprehensive data from general population-based samples with clinically collected measurements spanning generations. This study utilized nationally representative data to assess the risk of developing hypertension in offspring based on parental hypertension status, employing standardized blood pressure measurements rather than relying solely on historical data. A positive correlation exists between the increasing number of hypertensive parents and the risk of hypertension development in offspring. The prevalence of hypertension among individuals aged 10 to 18 years did not substantially increase with age. Adolescents whose parents were affected by hypertension exhibited a 2-fold greater prevalence of hypertension compared to the general population with the same age, with approximately a quarter of boys with both hypertensive parents having hypertension. Among nonobese individuals, the risk of hypertension associated with parental hypertension was comparable to that observed in obese subjects. Blood pressure monitoring from the early stage of life would benefit adolescents with hypertensive parents.

Clinical guidelines for the diagnosis, evaluation, and management of hypertension for Korean children and adolescents: the Korean Working Group of Pediatric Hypertension

Pediatric hypertension (HTN) is a significant, growing health concern worldwide and also in Korea. Diagnosis, evaluation, and treatment of HTN in Korean children and adolescents are uncertain due to limitations in using the current international guidelines, since the recommendations by the American Academy of Pediatrics (AAP) and European Society of Hypertension (ESH) guidelines differ. Furthermore, these are guidelines for Western youth, who are racially and ethnically different from Koreans. In addition, reference blood pressure values for all pediatric age groups, which are essential for the diagnosis of HTN according to these two guidelines, are absent in Korea. Therefore, HTN guidelines for Korean children and adolescents should be established. The Korean Working Group of Pediatric Hypertension established clinical guidelines for the diagnosis, evaluation, and management of HTN in Korean children and adolescents. These guidelines were based on reported clinical evidence, expert recommendations, and AAP and ESH guidelines. The characteristics of Korean youth and the Korean medical and insurance system were considered during the establishment of the guidelines. By providing recommendations suitable for Korean youth, these guidelines will help in the prevention and management of childhood HTN, thus relieving the burden of cardiovascular disease in adulthood in Korea.

Long-Term Cardiovascular Outcomes in Children and Adolescents With Hypertension

Importance

Hypertension affects 6% of all children, and its prevalence is increasing. Childhood hypertension tracks into adulthood and is associated with subclinical cardiovascular disease; however, there is a lack of evidence linking childhood hypertension to cardiovascular outcomes, which may contribute to underdiagnosis and undertreatment.

Objective

To determine the long-term associated risk of major adverse cardiac events (MACE) among children diagnosed with hypertension.

Design, Setting, and Participants

This was a population-based, retrospective, matched cohort study conducted from 1996 to 2022. The study included all children (aged 3-18 years) alive in Ontario, Canada, from 1996 to 2021, who were identified using provincial administrative health databases. Children with prior kidney replacement therapy were excluded.

Exposure

Incident hypertension diagnosis, identified by validated case definitions using diagnostic and physician billing claims. Each case was matched with 5 controls without hypertension by age, sex, birth weight, maternal gestational hypertension, prior comorbidities (chronic kidney disease, diabetes, cardiovascular surgery), and a propensity score for hypertension.

Main Outcomes and Measures

The primary outcome was MACE (a composite of cardiovascular death, stroke, hospitalization for myocardial infarction or unstable angina, or coronary intervention). Time to MACE was evaluated using the Kaplan-Meier method and Cox proportional hazards regression.

Results

A total of 25 605 children (median [IQR] age, 15 [11-17] years; 14 743 male [57.6%]) with hypertension were matched to 128 025 controls without hypertension. Baseline covariates were balanced after propensity score matching, and prior comorbidities were uncommon (hypertension vs control cohort: malignancy, 1451 [5.7%] vs 7908 [6.2%]; congenital heart disease, 1089 [4.3%] vs 5408 [4.2%]; diabetes, 482 [1.9%] vs 2410 [1.9%]). During a median (IQR) of 13.6 (7.8-19.5) years of follow-up, incidence of MACE was 4.6 per 1000 person-years in children with hypertension vs 2.2 per 1000 person-years in controls (hazard ratio, 2.1; 95% CI, 1.9-2.2). Children with hypertension were at higher associated risk of stroke, hospitalization for myocardial infarction or unstable angina, coronary intervention, and congestive heart failure, but not cardiovascular death, compared with nonhypertensive controls.

Conclusions and Relevance

Children diagnosed with hypertension had a higher associated long-term risk of MACE compared with controls without hypertension. Improved detection, follow-up, and control of pediatric hypertension may reduce the risk of adult cardiovascular disease.

Evaluation of endothelial dysfunction in hypertensive children and adolescents

BACKGROUND

Atherosclerotic changes can be attributed to early endothelial damage in individuals with hypertension. We aimed to explore the relationship between endothelial dysfunction and hypertension in newly diagnosed children without end-organ damage, considering carotid intima-media thickness (CIMT), flow-mediated dilatation (FMD), and functional capillaroscopy parameters. We also analyzed the differences between dipper and non-dipper patients.

METHODS

In this cross-sectional study, 20 patients diagnosed with essential hypertension with no target organ damage, and 20 age and sex-matched healthy volunteers were enrolled. The patient group comprised newly diagnosed individuals not receiving antihypertensive treatment. Hypertensive patients were divided into two groups (dipper and non-dipper patients). The measurements of CIMT, brachial FMD, and functional capillaroscopy were performed before starting treatment.

RESULTS

Among the patients, 11 were boys, and 9 were girls, with a median age of 16.0 (2.13) years. Of 20 hypertensive patients, 10 were dipper and 10 were non-dipper. Significant differences were observed between the hypertensive patients and controls in terms of CIMT (p = 0.04), brachial artery FMD (p = 0.02), and functional capillary density (p < 0.001). Hypertensive patients exhibited increased CIMT, reduced brachial artery FMD, and lower capillary density. However, there were no differences between dippers and non-dippers regarding age, sex, height SDS, weight SDS, CIMT SDS, brachial artery FMD, and capillary density.

CONCLUSIONS

Understanding the vascular consequences associated with essential hypertension emphasizes the importance of early detection and management of hypertension. Herein, we have effectively highlighted significant endothelial changes through the analysis of three parameters in newly diagnosed children without apparent target organ damage.

Impact of Lipids and Vascular Damage on Early Atherosclerosis in Adolescents with Parental Premature Coronary Artery Disease

AIM

To assess the relationship of cardiovascular risk factors (CRFs) with carotid intima media thickness (IMT) in adolescents with a parental history of premature coronary artery disease (PCAD).

METHODS

This cross-sectional study included 50 healthy adolescents, aged 14-18 years, both sexes, with a parental history of PCAD, that were compared to 50 controls without this history. Questionnaires regarding information of CRFs were applied. Blood chemistry analyses, included lipid profile, lipoprotein (a), low density lipoprotein (LDL) susceptibility to oxidation, and inflammatory cytokine levels. The IMT was evaluated by ultrasound.

RESULTS

The mean age of all participants was 15.9 years. Anthropometric measurements, blood pressure, and lipid profile were similar in both groups. However, the parental history of PCAD group exhibited lower high density lipoprotein cholesterol concentrations, shorter LDL particle oxidation time, and higher lipoprotein (a) levels compared to the control group. IMT was significantly higher in adolescents with a parental history of PCAD compared to controls, (0.53 ± 0.04 mm vs 0.47 ± 0.02 mm, p = 0.001). Among adolescents with a parental history of PCAD, those with ≥ 3 CRFs had significantly higher IMT values (0.56 mm) than those with < 3 CRFs (0.52 mm) and controls (0.48 mm). Multivariable analyses identified that systolic blood pressure and parental history of PCAD explained 26.8% and 16.1% of the variation in IMT. Furthermore, body mass index, LDL-C, ApoB-100, triglycerides and lipoprotein (a) interact with blood pressure levels to explain the IMT values.

CONCLUSION

Adolescents with a parental history of PCAD had higher IMT values than the control group, primary explained by systolic blood pressure and the parental inheritance. Adolescents with parental history of PCAD and ≥ 3 CRFs exhibited the highest IMT values. Notably, lipids and systolic blood pressure jointly contribute to explain IMT in these adolescents.

Determinants of vascular structure and function in at-risk children born to mothers managed for pre-eclampsia (FINNCARE study)

Background and aim

Pre-eclampsia (PE) is related to elevated blood pressure (BP) in children. The study aims to investigate if elevated BP is reflected in child arterial health and how anthropometrics, body composition, and gestational and perinatal factors influenced this.

Methods

In this prospective cohort study, we assessed the arteries of 182 children exposed (46 had an early onset, with a diagnosis before 34 gestational weeks, and 136 had a late onset) and 85 children unexposed (non-PE) to PE at 8-12 years from delivery using ultra-high-frequency ultrasound in addition to ambulatory and central BPs, body composition and anthropometrics, and tonometry-derived pulse wave velocity (PWV).

Results

No differences were found in intima-media thickness (IMT), adventitia thickness (AT), lumen diameter (LD), local carotid artery stiffness, distensibility, or wall stress between PE-exposed and non-PE-exposed children. All children's brachial, radial, and femoral artery IMTs were associated with 24-h systolic BP (SBP) and pulse pressure, carotid-femoral PWV, and anthropometric measures. The 24-h SBP and anthropometrics, notably lean body mass, were independent predictors of peripheral artery IMTs (brachial R2 = 0.217, radial R2 = 0.208, femoral R2 = 0.214; p < 0.001). Head circumference predicted carotid artery IMT and LD (β = 0.163, p = 0.009; β = 0.417, p < 0.001, respectively), but carotid artery IMT was not associated with BP. No independent associations were found for peripheral artery ATs. Local carotid artery stiffness, distensibility, and wall stress were independently associated with adiposity. No significant associations were found between gestational or perinatal factors and child vascular health parameters.

Conclusions

The peripheral artery IMT of PE-exposed children is identical to that of non-PE-exposed children, but associated with BP. Adiposity is related to local carotid artery stiffness. These adverse associations in arterial health may reflect the early progression of cardiovascular disease in PE-exposed children.

Childhood infection burden, recent antibiotic exposure and vascular phenotypes in preschool children

BACKGROUND

Severe childhood infection has a dose-dependent association with adult cardiovascular events and with adverse cardiometabolic phenotypes. The relationship between cardiovascular outcomes and less severe childhood infections is unclear.

AIM

To investigate the relationship between common, non-hospitalised infections, antibiotic exposure, and preclinical vascular phenotypes in young children.

DESIGN

A Dutch prospective population-derived birth cohort study.

METHODS

Participants were from the Wheezing-Illnesses-Study-Leidsche-Rijn (WHISTLER) birth cohort. We collected data from birth to 5 years on antibiotic prescriptions, general practitioner (GP)-diagnosed infections, and monthly parent-reported febrile illnesses (0-1 years). At 5 years, carotid intima-media thickness (CIMT), carotid artery distensibility, and blood pressure (BP) were measured. General linear regression models were adjusted for age, sex, smoke exposure, birth weight z-score, body mass index, and socioeconomic status.

RESULTS

Recent antibiotic exposure was associated with adverse cardiovascular phenotypes; each antibiotic prescription in the 3 and 6 months prior to vascular assessment was associated with an 18.1 μm (95% confidence interval, 4.5-31.6, p = 0.01) and 10.7 μm (0.8-20.5, p = 0.03) increase in CIMT, respectively. Each additional antibiotic prescription in the preceding 6 months was associated with an 8.3 mPa-1 decrease in carotid distensibility (-15.6- -1.1, p = 0.02). Any parent-reported febrile episode (compared to none) showed weak evidence of association with diastolic BP (1.6 mmHg increase, 0.04-3.1, p = 0.04). GP-diagnosed infections were not associated with vascular phenotypes.

CONCLUSIONS

Recent antibiotics are associated with adverse vascular phenotypes in early childhood. Mechanistic studies may differentiate antibiotic-related from infection-related effects and inform preventative strategies.

Office blood pressure versus ambulatory blood pressure measurement in childhood obesity

BACKGROUND

The prevalence of obesity-related co-morbidities is rising parallel to the childhood obesity epidemic. High blood pressure (BP), as one of these co-morbidities, is detected nowadays at increasingly younger ages. The diagnosis of elevated BP and hypertension, especially in the childhood population, presents a challenge to clinicians. The added value of ambulatory blood pressure measurement (ABPM) in relation to office blood pressure (OBP) measurements in obese children is unclear. Furthermore, it is unknown how many overweight and obese children have an abnormal ABPM pattern. In this study we evaluated ABPM patterns in a population of overweight and obese children and adolescents, and compared these patterns with regular OBP measurements.

METHODS

In this cross-sectional study in overweight or obese children and adolescents aged 4-17 years who were referred to secondary pediatric obesity care in a large general hospital in The Netherlands, OBP was measured during a regular outpatient clinic visit. Additionally, all participants underwent a 24-hour ABPM on a regular week-day. Outcome measures were OBP, mean ambulatory SBP and DBP, BP load (percentage of readings above the ambulatory 95th blood pressure percentiles), ambulatory BP pattern (normal BP, white-coat hypertension, elevated BP, masked hypertension, ambulatory hypertension), and BP dipping.

RESULTS

We included 82 children aged 4-17 years. They had a mean BMI Z-score of 3.3 (standard deviation 0.6). Using ABPM, 54.9% of the children were normotensive (95% confidence interval 44.1-65.2), 26.8% had elevated BP, 9.8% ambulatory hypertension, 3.7% masked hypertension, and 4.9% white-coat hypertension. An isolated night-time BP load > 25% was detected in almost a quarter of the children. 40% of the participants lacked physiologic nocturnal systolic BP dipping. In the group of children with normal OBP, 22.2% turned out to have either elevated BP or masked hypertension on ABPM.

CONCLUSIONS

In this study a high prevalence of abnormal ABPM patterns in overweight or obese children and adolescents was detected. Additionally, OBP poorly correlated with the child's actual ABPM pattern. Herewith, we emphasized the usefulness of ABPM as an important diagnostic tool in this population.

N-of-1 Trials vs. Usual Care in Children With Hypertension: A Pilot Randomized Clinical Trial

BACKGROUND

Blood pressure (BP) is often inadequately controlled in children treated for hypertension, and personalized (n-of-1) trials show promise for tailoring treatment choices. We assessed whether patients whose treatment choices are informed by an n-of-1 trial have improved BP control compared to usual care.

METHODS

A randomized clinical trial was conducted in a pediatric hypertension clinic in Houston from April 2018 to September 2020. Hypertensive adolescents and young adults 10-22 years old were randomized 1:1 to a strategy of n-of-1 trial using ambulatory BP monitoring to inform treatment choice or usual care, with treatment selected by physician preference. The primary outcome was the proportion of patients with ambulatory BP control at 6 months in a Bayesian analysis.

RESULTS

Among 49 participants (23 randomized to n-of-1 trials and 26 to usual care), mean age was 15.6 years. Using skeptical priors, we found a 69% probability that n-of-1 trials increased BP control at 6 months (Bayesian odds ratio (OR) 1.24 (95% credible interval (CrI) 0.51, 2.97), and 74% probability using neutral informed priors (OR 1.45 (95% CrI 0.48, 4.53)). Systolic BP was reduced in both groups, with a 93% probability of greater reduction in the n-of-1 trial group (mean difference between groups = -3.6 mm Hg (95% CrI -8.3, 1.28). There was no significant difference in side effect experience or caregiver satisfaction.

CONCLUSIONS

Among hypertensive adolescents and young adults, n-of-1 trials with ambulatory BP monitoring likely increased the probability of BP control. A large trial is needed to assess their use in clinical practice.

CLINICALTRIALS.GOV

NCT03461003.

CLINICAL TRIAL REGISTRY

ClinicalTrials.gov; NCT03461003.

Evaluation of Arterial Stiffness and Carotid Intima-Media Thickness in Children with Primary and Renal Hypertension

Hypertension is an increasing disease in children and the risk of endothelial damage and target organ damage increases in the presence of additional risk factors such as obesity. In our study, the effect of hypertension on early atherosclerotic changes and target organ damage in children was investigated. Twenty four-hour ambulatory pulse wave analysis was performed by oscillometric method in 71 children aged 8-18 years, 17 of whom were diagnosed with primary hypertension without obesity, 18 had both primary hypertension and obesity, and 16 had renal hypertension. Twenty healthy normotensive children were included as the control group. Carotid intima-media thickness (CIMT) and Left Ventricular Mass Index were measured. Central systolic blood pressure (cSBP), central diastolic blood pressure (cDBP), systolic blood pressure (SBP) and diastolic blood pressure (DBP) were higher in the primary hypertension group compared to controls (p = 0.001, p = 0.005, p = 0.001, p = 0.009, respectively), cSBP was higher in the renal hypertension group than the control group (p = 0.018). There was no difference between the groups in terms of pulse wave analysis parameters, CIMT, or left ventricular mass index (p > 0.05). Pulse wave velocity was positively correlated with SBP, DBP, cSBP, cDBP (p < 0.001). Augmentation index was positively correlated with DBP and cDBP (p = 0.01, p = 0.002, respectively). Our findings show that high blood pressure is associated with arterial stiffness and target organ damage beginning in childhood. The detection of early atherosclerotic vascular changes using pulse wave analysis allows to take necessary precautions such as lifestyle changes to prevent target organ damage in hypertensive children.

Prevalence of left ventricular hypertrophy in children and young people with primary hypertension: Meta-analysis and meta-regression

BACKGROUND

Left ventricular hypertrophy (LVH) is the main marker of HMOD in children and young people (CYP). We aimed to assess the prevalence of LVH and its determinants in CYP with primary hypertension (PH).

METHODS

A meta-analysis of prevalence was performed. A literature search of articles reporting LVH in CYP with PH was conducted in Medline, Embase, and Cochrane databases. Studies with a primary focus on CYP (up to 21 years) with PH were included. Meta-regression was used to analyze factors explaining observed heterogeneity.

RESULTS

The search yielded a total of 2,200 articles, 153 of those underwent full-text review, and 47 reports were included. The reports evaluated 51 study cohorts including 5,622 individuals, 73% male subjects, and a mean age of 13.6 years. LVH was defined as left ventricle mass index (LVMI) ≥ 95th percentile in 22 (47%), fixed cut-off ≥38.6 g/m2.7 in eight (17%), sex-specific fixed cut-off values in six (13%), and miscellaneously in others. The overall prevalence of LVH was 30.5% (95% CI 27.2-33.9), while heterogeneity was high (I 2 = 84%). Subgroup analysis including 1,393 individuals (76% male subjects, mean age 14.7 years) from pediatric hypertension specialty clinics and LVH defined as LVMI ≥95th percentile only (19 study cohorts from 18 studies), reported prevalence of LVH at 29.9% (95% CI 23.9 to 36.3), and high heterogeneity (I 2 = 84%). Two studies involving patients identified through community screening (n = 1,234) reported lower LVH prevalence (21.5%). In the meta-regression, only body mass index (BMI) z-score was significantly associated with LVH prevalence (estimate 0.23, 95% CI 0.08-0.39, p = 0.004) and accounted for 41% of observed heterogeneity, but not age, male percentage, BMI, or waist circumference z-score. The predominant LVH phenotype was eccentric LVH in patients from specialty clinics (prevalence of 22% in seven studies with 779 participants) and one community screening study reported the predominance of concentric LVH (12%).

CONCLUSION

Left ventricular hypertrophy is evident in at least one-fifth of children and young adults with PH and in nearly a third of those referred to specialty clinics with a predominant eccentric LVH pattern in the latter. Increased BMI is the most significant risk association for LVH in hypertensive youth.

Vascular biomarkers in the prevention of childhood cardiovascular risk: From concept to clinical implementation

Vascular biomarkers allow for non-invasive assessment of vascular structure and function and have been shown to be surrogates for cardiovascular (CV) outcome in adults. They reflect the cumulative risk of a plethora of single CV risk factors, such as obesity and hypertension, on the arterial wall. The process of atherosclerosis oftentimes has its origin in childhood and tracks into adulthood. Obesity-related CV risk in childhood is a main determinant of manifest CV disease and adverse outcome in adulthood. To date, prevention strategies are directed toward the detection and reduction of CV disease in adulthood. This review updates and puts into perspective the potential use of vascular biomarkers in children. With reference to the concept of early vascular aging in adults, it elaborates on the role of vascular biomarkers for CV risk stratification in children. The concept of primordial vascular aging implies that young children be screened for vascular health, in an attempt to timely detect subclinical atherosclerosis and initiate treatment strategies to reverse vascular damage in a period of life with high probability for risk regression. The evidence for the validity of macro- and microvascular candidate biomarkers as screening tools of CV risk in children is reviewed, and limitations as well as remaining research gaps are highlighted. Furthermore, an overview on the effects of exercise treatment on vascular biomarkers is given. Vascular biomarkers susceptible to lifestyle or drug treatment have the potential to qualify as monitoring tools to guide clinicians. This review discusses evidence for vascular biomarkers to optimize screening of childhood CV risk from initial concepts to potential future clinical implementation in cardiovascular prevention.

Current applications for measuring pediatric intima-media thickness

Intima-media thickness is a known subclinical radiologic marker of the early manifestations of atherosclerotic disease. It is the thickness of the vessel wall, most often the carotid artery. Intima-media thickness is measured on conventional US manually or automatically. Other measurement techniques include radiofrequency US. Because there is variation in its measurement, especially in children, several recommendations have been set to increase the measurement's validity and comparability among studies. Despite these recommendations, several pitfalls should be avoided, and quality control should be performed to avoid erroneous interpretation. This article summarizes current literature in relation to the clinical applications for intima-media thickness measurement in children with known risk factors such as obesity, liver steatosis, hypercholesterolemia, diabetes, hypertension, systemic inflammatory diseases, cancer survival, kidney and liver transplant, and sickle cell disease or beta thalassemia major. Most potential indications for intima-media thickness measurement remain in the research domain and should be interpreted combined with other markers. The objective of diagnosing an increased intima-media thickness is to start a multidisciplinary treatment approach to prevent disease progression and its sequelae in adulthood.

Breastfeeding Duration and High Blood Pressure in Children and Adolescents: Results from a Cross-Sectional Study of Seven Provinces in China

This study was aimed to investigate the associations between breastfeeding duration and blood pressure (BP) levels, BP Z scores and high BP (HBP) in children and adolescents. A total of 57,201 participants including 29,491 boys and 27,710 girls aged 7−18 years were recruited from seven provinces in China in 2012. HBP was defined as BP levels of ≥95th percentiles of the referent age-, sex-, and height-specific population. Breastfeeding duration was divided into non-breastfeeding, 0−5 months, 6−12 months, and >12 months. Information on demographic, parental or family factors and dietary behaviors was collected through a self-administered questionnaire. Multivariable linear regression and logistic regression models were applied to assess the relationships of breastfeeding duration with BP levels and BP Z scores and with HBP, respectively. Stratified analyses were performed to further investigate the potential subgroup-specific associations. The reported prolonged breastfeeding (>12 months) rate was 22.53% in the total population. After full adjustment, compared to the non-breastfeeding group, breastfeeding for 6−12 months was correlated with 0.43 (95% CI: −0.75, −0.11) and 0.36 (95% CI: −0.61, −0.12) mmHg lower levels of SBP and DBP, respectively. Similar decrease trends were found for BP Z scores. Prolonged breastfeeding (>12 months) was associated with 1.33 (95% CI: 1.12, 1.58) and 1.12 (95% CI: 0.94, 1.33) higher odds of HBP in boys and girls, respectively. Based on nationally representative data, there was no evidence that a longer duration of breastfeeding is protective against childhood HBP. Breastfeeding for 6−12 months may be beneficial to BP, while prolonged breastfeeding durations might increase the odds of HBP in children and adolescents.

Pediatric hypertension screening and recognition in primary care clinics in Canada

Objectives

Screening for hypertension in children is recommended by pediatric consensus guidelines. However, current practice is unknown. We evaluated rates of blood pressure assessment and hypertension recognition in primary care.

Methods

This retrospective cohort study evaluated electronic medical record data from the Canadian Primary Care Sentinel Surveillance Network between 2011 and 2017. Children aged 3 to <18 years with at least one clinical encounter were included. Screening, follow-up, and hypertension recognition rates were evaluated. Descriptive statistics and multivariate logistical regression were used to determine patient and provider characteristics associated with increased screening and recognition of pediatric hypertension.

Results

Among 378,002 children, blood pressure was documented in 33.3% of all encounters, increasing from 26.7% in 2011 to 36.2% in 2017; P=0.007. Blood pressure was documented in 76.0% of well child visits. Follow-up visits occurred within 6 months for 26.4% of children with elevated blood pressure, 57.1% of children with hypertension, and within 1 month for 7.2% of children with hypertension. Patient factors associated with increased blood pressure screening include being overweight (OR 2.15, CI 2.09 to 2.22), having diabetes (OR 1.69, CI 1.37 to 2.08), chronic kidney disease (OR 7.51, CI 6.54 to 8.62), increased social deprivation (OR 1.10, CI 1.09 to 1.11), and urban residence (OR 1.27, CI 1.15 to 1.4). Overall prevalence of hypertension was 1.9% (n=715) and of those, 5.6% (n=40) had recognized hypertension. Factors associated with increased recognition include male sex, overweight, and hyperlipidemia.

Conclusions

Rates of hypertension screening and recognition are low in primary care settings in Canada, suggesting pediatric hypertension should be a priority for implementation and dissemination of interventions.

Objective Home-Monitoring of Physical Activity, Cardiovascular Parameters, and Sleep in Pediatric Obesity

<b><i>Introduction:</i></b> Clinical research and treatment of childhood obesity is challenging, and objective biomarkers obtained in a home-setting are needed. The aim of this study was to determine the potential of novel digital endpoints gathered by a home-monitoring platform in pediatric obesity. <b><i>Methods:</i></b> In this prospective observational study, 28 children with obesity aged 6–16 years were included and monitored for 28 days. Patients wore a smartwatch, which measured physical activity (PA), heart rate (HR), and sleep. Furthermore, daily blood pressure (BP) measurements were performed. Data from 128 healthy children were utilized for comparison. Differences between patients and controls were assessed via linear mixed effect models. <b><i>Results:</i></b> Data from 28 patients (average age 11.6 years, 46% male, average body mass index 30.9) and 128 controls (average age 11.1 years, 46% male, average body mass index 18.0) were analyzed. Patients were recruited between November 2018 and February 2020. For patients, the median compliance for the measurements ranged from 55% to 100% and the highest median compliance was observed for the smartwatch-related measurements (81–100%). Patients had a lower daily PA level (4,597 steps vs. 6,081 steps, 95% confidence interval [CI] 862–2,108) and peak PA level (1,115 steps vs. 1,392 steps, 95% CI 136–417), a higher nighttime HR (81 bpm vs. 71 bpm, 95% CI 6.3–12.3) and daytime HR (98 bpm vs. 88 bpm, 95% CI 7.6–12.6), a higher systolic BP (115 mm Hg vs. 104 mm Hg, 95% CI 8.1–14.5) and diastolic BP (76 mm Hg vs. 65 mm Hg, 95% CI 8.7–12.7), and a shorter sleep duration (difference 0.5 h, 95% CI 0.2–0.7) compared to controls. <b><i>Conclusion:</i></b> Remote monitoring via wearables in pediatric obesity has the potential to objectively measure the disease burden in the home-setting. The novel endpoints demonstrate significant differences in PA level, HR, BP, and sleep duration between patients and controls. Future studies are needed to determine the capacity of the novel digital endpoints to detect effect of interventions.

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.

Glycogen storage disease type I patients with hyperlipidemia have no signs of early vascular dysfunction and premature atherosclerosis

BACKGROUND AND AIMS

Glycogen storage disease type I (GSD I) is associated with hyperlipidemia, a known risk factor for premature atherosclerosis. Few studies have addressed endothelial dysfunction in patients with GSD I, and these studies yielded controversial results.

METHODS AND RESULTS

We investigated vascular dysfunction in a cohort of 32 patients with GSD I (26 GSD Ia, 6 GSD Ib, mean age 20.7 (4.8-47.5) years) compared to 32 age-, gender-, and BMI-matched healthy controls using non-invasive techniques such as quantification of carotid intima media thickness, retinal vessel analysis and 24 h-blood pressure measurements. In addition, early biomarkers of inflammatory and oxidative endothelial stress were assessed in blood. Although GSD I patients had a clearly proatherogenic lipid profile, increased oxidative stress, higher levels of high sensitivity C-reactive protein and increased lipoprotein associated phospholipase A2 activity, functional and structural parameters including carotid intima media thickness and retinal vessel diameters did not indicate premature atherosclerosis in this patient cohort. Blood pressure values and pulse wave velocity were comparable in patients and healthy controls, while central blood pressure and augmentation index were higher in GSD patients.

CONCLUSION

Our data suggest that GSD I is not associated with early vascular dysfunction up to the age of at least 20 years. Further studies are needed to elucidate the possibly protective mechanisms that prevent early atherosclerosis is GSD I. Longer follow-up studies are required to assess the long-term risk of vascular disease with increased oxidative stress being present in GSD I patients.

Identification of Adolescents with Adiposities and Elevated Blood Pressure and Implementation of Preventive Measures Warrants the Use of Multiple Clinical Assessment Tools

The burden of abdominal adiposity has increased globally, which is recognized as a key condition for the development of obesity-related disorders among youth, including type 2 diabetes, cardiovascular disease, and hypertension. High blood pressure (BP) and cardiovascular diseases increase the rates of premature mortality and morbidity substantially. Aims: to investigate the relation between abdominal adiposity and elevated BP among adolescent males in Jordan. Methods: Nationally representative sample of male adolescents was selected using multi-cluster sampling technique. Study sample included 1035 adolescent males aged 12 to 17 years. Multiple indicators were used to assess adiposity including waist circumference (WC) and total body fat (TF), truncal fat (TrF), and visceral fat (VF). Systolic blood pressure was measured to assess hypertension. Results: After adjusting for age, smoking status, and physical activity, the odds of having stage two hypertension increased 6, 7, and 8 times for adolescents who were on 90th percentile or above for Trf, VF, and WC, respectively. Conclusion: Elevated BP was significantly associated with total and abdominal adiposity among adolescent males in Jordan. Use of multiple clinical assessment tools is essential to assess abdominal obesity among adolescents.

Influence of Blood Pressure Percentile Reporting on the Recognition of Elevated Blood Pressures

OBJECTIVES

To explore the impact of displaying blood pressure (BP) percentiles with BP readings in the electronic health record (EHR) on the recognition of children with elevated blood pressures (EBPs).

METHODS

This was a retrospective cohort study of children (ages 1-17), including inpatients and outpatients, with at least 1 EHR noninvasive BP recording. In phase 1, BP percentiles were calculated, stored, and not displayed to clinicians. In phase 2, percentiles were displayed adjacent to the EHR BP. Encounters with 1 BP ≥95th percentile were classified as elevated. EBP recognition required the presence of at least 1 EBP-related International Classification of Diseases, Ninth Revision or International Classification of Diseases, 10th Revision code. We compared recognition frequencies across phases with logistic regression.

RESULTS

In total, 45 504 patients in 115 060 encounters were included. Inpatient recognition was 4.1% (238 of 5572) in phase 1 and 5.5% (338 of 5839) in phase 2. The adjusted odds ratio (OR) associated with the intervention was 1.22 (95% confidence interval [CI]: 0.90-1.66). Outpatient recognition rates were 8.0% (1096 of 13 725 EBP encounters) in phase 1 and 9.7% (1442 of 14 811 encounters) in phase 2. The adjusted OR was 1.296 (95% CI: 0.999-1.681). Overall, recognition rates were higher in boys (outpatient OR: 1.51; 95% CI: 1.15-1.98) and older children (outpatient/inpatient OR: 1.08/1.08; 95% CI: 1.05-1.11/1.05-1.11) and lower for those on a surgical service (outpatient/inpatient: OR: 0.41/0.38; 95% CI: 0.30-0.58/0.27-0.52).

CONCLUSIONS

Addition of BP percentiles to the EHR did not significantly change EBP recognition as measured by the addition of an EBP diagnosis code. Girls, younger children, and patients followed on a surgical service were less likely to have their EBP recognized by providers.

Hypertension and childhood stroke

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

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

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

The Effect of Long-Term Atorvastatin Therapy on Carotid Intima-Media Thickness of Children With Dyslipidemia

Carotid intima-media thickness (cIMT) has been proposed as an early marker of subclinical atherosclerosis in high risk children. Children with heterozygous familial hypercholesterolemia have greater cIMT than matched healthy controls or their unaffected siblings. Statin therapy may delay the progression of cIMT, although long-term studies in children are scarce. We evaluated the effect of atorvastatin treatment on cIMT in children with dyslipidemia. We studied 81 children/adolescents, 27 with severe dyslipidemia (low-density lipoprotein cholesterol [LDL-C] ≥190 mg/dL) and 54 sex- and age-matched healthy controls; LDL-C ≤ 130 mg/dL and lipoprotein (a), Lp(a), ≤30 mg/dL. In the children with dyslipidemia, cIMT was measured twice, before and on treatment (18.2 ± 7.7 months). Anthropometric data, a full lipid profile, liver, kidney, and thyroid function were evaluated. Males with dyslipidemia had a greater cIMT than male controls after adjustment for other factors (P = .049). In addition, a nonstatistically significant decrease in cIMT was observed after treatment (P = .261). Treatment with atorvastatin resulted in a significantly improved lipid profile. Females with dyslipidemia had a significantly thinner cIMT than males. Children with normal and high Lp(a) levels had similar cIMT values. In conclusion, treatment with atorvastatin had a beneficial effect on the lipid profile and cIMT progression in children with severe dyslipidemia.

Increased risk of metabolic dysfunction in children conceived by assisted reproductive technology

AIMS/HYPOTHESIS

Assisted reproductive technology (ART) is the most widely used treatment for infertility and has resulted in millions of births worldwide. The safety of the offspring has been of the utmost concern. Previous studies suggested an increase in metabolic disorders in offspring later in life. The aim of the present study was to investigate metabolic changes at age 6-10 years in offspring conceived as a result of in vitro fertilisation/intracytoplasmic sperm injection (IVF/ICSI).

METHODS

A total of 380 children born from IVF/ICSI and a matched control group of 380 naturally conceived children, all aged 6-10 years, were recruited. Anthropometric measures, ultrasound and serum tests were performed for body mass, glucose metabolism and lipid profiles, and examination of vasculature structure.

RESULTS

The children conceived by ART showed significantly higher fasting blood glucose and serum insulin levels and HOMA-IR (adjusted β [95% CI]: fasting blood glucose 0.49 [0.42, 0.55]; log_e-transformed insulin 0.28 [0.20, 0.35]; log_e-transformed HOMA-IR 0.38 [0.30, 0.46]), as well as a lower HOMA-B and serum apolipoprotein A (ApoA) levels (adjusted β [95% CI]: log_e-transformed HOMA-B -0.19 [-0.27, -0.11]; ApoA -0.17 [-0.21, -0.13]), when compared with the control group. Furthermore, the ultrasound scan indicated elevated carotid intima-media thickness in children conceived by ART (β 0.13 [95% CI 0.12, 0.13]).

CONCLUSIONS/INTERPRETATION

Children conceived by IVF/ICSI have a less favourable glucose and cardiovascular metabolic profile in childhood when compared with naturally conceived children. The underlying mechanisms and potential long-term consequences need to be elucidated in future studies. Graphical abstract.

Preventing Premature Atherosclerotic Disease

PURPOSE OF REVIEW

Cardiovascular disease (CVD) can begin in youth. Prevention is essential to reducing the burden of CVD-related risk factors in childhood and disease development in adulthood. This review addresses the clinical scope of CVD prevention, including a review of conditions encountered, proposed diagnostic criteria, and management strategies. We also highlight the impact of the intrauterine environment on the development of CVD risk. Finally, we highlight the potential role of telehealth in the management of pediatric patients with risk factors for premature CVD.

RECENT FINDINGS

Growing evidence suggests that maternal obesity, diabetes, and preeclampsia may play an important role in the development of CVD risk among offspring contributing to the development of known traditional CVD risk factors among offspring. As the prevalence of CVD continues to rise, knowledge as well as appropriate diagnosis and management of primordial and traditional risk factors for CVD is needed. The diagnosis and management of CVD risk factors is a central role of the preventive pediatric cardiologist, but it is imperative that the general physician and other pediatric subspecialists be aware of these risk factors, diagnoses, and management strategies. Finally, telehealth may offer an additional method for providing preventive care, including screening and counseling of at risk children and adolescents for traditional risk factors and for providing education regarding risk factors in cases of long distance care and/or during periods of social distancing.

Increased blood pressure is associated with increased carotid artery intima-media thickness in children with repaired coarctation of the aorta

OBJECTIVES

The intima-media thickness of the common carotid artery (cIMT) is a good noninvasive surrogate marker for cardiovascular disease. Regular cIMT monitoring in children with congenital heart disease has great potential. We sought to determine which anthropomorphic and haemodynamic variables were significantly associated with the cIMT in paediatric patients with obesity and children with repaired coarctation of the aorta (CoA).

METHODS

We measured the cIMT in 143 children aged 5 to less than 18 years including normal weight controls (n = 44), children with overweight/obesity (n = 73) and children with repaired CoA (n = 26). cIMT was compared and the association between the cIMT and patient characteristics, including obesity and blood pressure (BP), was investigated.

RESULTS

BMI z score, sex and the presence of CoA were significant independent predictors of cIMT. The cIMT was significantly greater in children with overweight/obesity (0.53 ± 0.06 mm) relative to normal weight controls (0.51 ± 0.04 mm), as well as in CoA patients with abnormally high BP (0.57 ± 0.08 mm) versus CoA patients with normal BP (0.52 ± 0.05 mm) and controls (0.51 ± 0.04 mm). CoA patients with normal BP did not have significantly increased cIMT.

CONCLUSION

cIMT was positively associated with BMI z score, male sex and CoA repair in children. The increased cIMT in children with repaired CoA was because of those with abnormally high BP, which was masked in clinic for most of these patients. These findings warrant further investigations into the cIMT and other atherosclerotic risk factors to determine their potential clinical impact in these highly susceptible patients.

Nocturnal blood pressure dipping as a marker of endothelial function and subclinical atherosclerosis in pediatric-onset systemic lupus erythematosus

Background

Loss of the normal nocturnal decline in blood pressure (BP), known as non-dipping, is a potential measure of cardiovascular risk identified by ambulatory blood pressure monitoring (ABPM). We sought to determine whether non-dipping is a useful marker of abnormal vascular function and subclinical atherosclerosis in pediatric-onset systemic lupus erythematosus (pSLE).

Methods

Twenty subjects 9–19 years of age with pSLE underwent ABPM, peripheral endothelial function testing, carotid-femoral pulse wave velocity/analysis for aortic stiffness, and carotid intima-media thickness. We assessed the prevalence of non-dipping and other ABPM abnormalities. Pearson or Spearman rank correlation tests were used to evaluate relationships between nocturnal BP dipping, BP load (% of abnormally elevated BPs over 24-h), and vascular outcome measures.

Results

The majority (75%) of subjects had inactive disease, with mean disease duration of 3.2 years (± 2.1). The prevalence of non-dipping was 50%, which occurred even in the absence of nocturnal or daytime hypertension. Reduced diastolic BP dipping was associated with poorer endothelial function (r 0.5, p = 0.04). Intima-media thickness was significantly greater in subjects with non-dipping (mean standard deviation score of 3.0 vs 1.6, p = 0.02). In contrast, higher systolic and diastolic BP load were associated with increased aortic stiffness (ρ 0.6, p = 0.01 and ρ 0.7, p < 0.01, respectively), but not with endothelial function or intima-media thickness.

Conclusion

In a pSLE cohort with low disease activity, isolated nocturnal BP non-dipping is prevalent and associated with endothelial dysfunction and atherosclerotic changes. In addition to hypertension assessment, ABPM has a promising role in risk stratification and understanding heterogeneous mechanisms of cardiovascular disease in pSLE.

Pediatric Obesity, Hypertension, Lipids

PURPOSE OF REVIEW

The rise of the pediatric obesity pandemic over the past 40 years has sharpened focus on the management of obesity, hypertension and lipid abnormalities in children. Multiple studies demonstrate that these risk factors track from childhood into adulthood predisposing individuals to premature atherosclerotic cardiovascular disease and putting them at risk for early morbidity and mortality.

RECENT FINDINGS

Importantly, obesity, hypertension and lipid problems are individual risk factors that can occur independently. Multiple studies have shown that each risk factor causes target organ damage in children. Intensive and focused lifestyle modifications can improve a child's subclinical disease and decrease the risk for future morbidity.

SUMMARY

Childhood offers a unique opportunity at primordial and primary prevention of atherosclerotic cardiovascular disease. Clinicians must focus on targeting these highly prevalent conditions and applying lifestyle modification and then pharmacologic or surgical therapies as needed.

Critical review of nutrition, blood pressure and risk of hypertension through the lifecycle: do B vitamins play a role?

Hypertension is the leading cause of preventable mortality worldwide, contributing to over 9 million deaths per annum, predominantly owing to cardiovascular disease. The association of obesity, physical inactivity and alcohol with elevated blood pressure (BP) is firmly established. Weight loss or other dietary strategies, such as the Dietary Approaches to Stop Hypertension (DASH) diet, have been shown to be effective in lowering BP. Additionally, specific nutrients are recognised to contribute to BP, with higher sodium intake linked with an increased risk of hypertension, while potassium is associated with a reduced risk of hypertension. Of note, emerging evidence has identified a novel role for one-carbon metabolism and the related B vitamins, particularly riboflavin, in BP. Specifically in adults genetically at risk of developing hypertension, owing to the common C677T polymorphism in MTHFR, supplemental riboflavin (co-factor for MTHFR) was shown in randomised trials to lower systolic BP by up to 13 mmHg. A BP response to intervention of this magnitude could have important clinical impacts, given that a reduction in systolic BP of 10 mmHg is estimated to decrease stroke risk by 40%. This review aims to explore the factors contributing to hypertension across the lifecycle and to critically evaluate the evidence supporting a role for nutrition, particularly folate-related B vitamins, in BP and risk of hypertension. In addition, gaps in our current knowledge that warrant future research in this area, will be identified.

Cardiorespiratory fitness, adiposity, and ambulatory blood pressure in adolescents

BACKGROUND

This study examined the association of cardiorespiratory fitness (fitness) and adiposity (Body Mass Index [BMI] and waist circumference [WC]) with ambulatory blood pressure (ABP) and tested the moderating effect of adiposity on the association between fitness and ABP.

METHODS

A cross-sectional study was conducted with 370 adolescents aged 11-16 years. Fitness was assessed by a height-adjusted step test and estimated by heart rate recovery, defined as the difference between peak heart rate during exercise and heart rate two minutes postexercise. Adiposity was measured using dichotomized values for percentiles of BMI (≥85th) and WC (≥50th). ABP was measured every 30-60 minutes over 24 hours on a school day. Mixed-effects regression analysis was used.

RESULTS

Each unit increase in fitness was associated with a decrease of systolic blood pressure (SBP) [-0.058 mmHg, P=0.001] and diastolic blood pressure (DBP) [-0.043 mmHg, P<0.001] after adjustment for WC and covariates. Each unit increase in fitness was associated with a decrease in SBP [-0.058 mmHg, P=0.001] and DBP [-0.045 mmHg, P<0.001] after adjustment for BMI and covariates. Fitness and BMI≥85th percentile (or WC ≥ 50th percentile) interactions were not associated with ABP after adjustment for covariates.

CONCLUSIONS

Our findings indicate a small but statistically significant inverse effect of fitness on ABP in adolescents. No evidence of a modifying effect of adiposity on this association suggesting that fitness and weight management have essential roles for maintaining lower ABP in adolescents.

Ambulatory blood pressure and carotid intima media thickness in children with type 1 diabetes

BACKGROUND/OBJECTIVE

Blood pressure abnormalities may play an important role in macrovascular damage in type 1 diabetes. Little is known about blood pressure abnormalities and macrovascular damage in children with type 1 diabetes.

METHODS

Children with type 1 diabetes (n = 57) for a short (3 months-2 years; n = 24) or long duration (≥5 years; n = 33) and a group of control children without diabetes (n = 29) completed 24-h ambulatory blood pressure monitoring (ABPM). Carotid intima media thickness (cIMT), a subclinical indicator of atherosclerosis, was assessed by carotid ultrasound.

RESULTS

ABPM abnormalities were more prevalent (57% vs 24%, respectively), and daytime, nighttime and 24-h systolic, diastolic, and mean arterial blood pressure indices were higher in children with type 1 diabetes compared to control children. The odds estimate of an ABPM abnormality was 6.68 (95% confidence interval: 1.95, 22.9; P = .003) in children with type 1 diabetes compared to controls after adjusting for age, sex, and BMI standardized for age and sex (zBMI). An interaction between ABPM and zBMI on cIMT was observed. In children with type 1 diabetes and ABPM abnormalities, every 1 SD increase in zBMI was associated with a 0.030 mm increase in cIMT (95% confidence interval: 0.002, 0.041; P = .031). This was not observed in control children with ABPM abnormalities or in children with normal ABPM, regardless of type 1 diabetes status.

CONCLUSIONS

Children with type 1 diabetes have a high prevalence of ABPM abnormalities independent of disease duration and this is related to early indicators of cardiovascular damage.

Clinical Innovation: A Multidisciplinary Program for the Diagnosis and Treatment of Systemic Hypertension in Children and Adolescents

Pediatric systemic hypertension (HTN) is underdiagnosed and undertreated. The Divisions of Cardiology and Nephrology at our institution developed a comprehensive outpatient HTN program to (1) screen children at risk for HTN, (2) assess cardiovascular health, and (3) optimize medical management. We report our findings during all initial visits (n = 304) from December 2011 to September 2018. Of the cohort, 38% were obese and 36% reported little to no exercise. More than half of patients ≥11 years old did not have recommended lipid screening. When evaluating ambulatory blood pressure monitoring results, clinic blood pressure did not accurately diagnose patients with or without HTN and many patients on antihypertensive medications were inadequately treated. Visit recommendations included addition of or changes to antihypertensive medication in 35% of patients. A multidisciplinary program dedicated to pediatric HTN helps screen patients who are at risk. Ambulatory blood pressure monitoring identifies HTN in patients with normal clinic blood pressure and those on antihypertensive medication.

A Comparison of Metabolic Outcomes Between Obese HIV-Exposed Uninfected Youth From the PHACS SMARTT Study and HIV-Unexposed Youth From the NHANES Study in the United States

BACKGROUND

Metabolic perturbations in HIV-exposed uninfected (HEU) obese youth may differ from those in the general obese pediatric population.

METHODS

Metabolic parameters of obese (body mass index Z-score >95th percentile) HEU youth in the Pediatric HIV/AIDS Cohort Study (PHACS) Surveillance Monitoring of ART Toxicities (SMARTT) study were compared with a matched sample of obese youth from the US National Health and Nutrition Examination Survey (NHANES). We evaluated systolic and diastolic hypertension (blood pressure ≥90th percentile for age, sex, and height), total cholesterol >200 mg/dL, high-density lipoprotein cholesterol <35 mg/dL, low-density lipoprotein cholesterol >130 mg/dL, triglycerides (TGs) >150 mg/dL, and Homeostatic Model Assessment-Insulin Resistance >4.0. Modified Poisson regression models were fit to quantify the prevalence ratio (PR) of each outcome comparing the 2 cohorts, adjusting for confounders.

RESULTS

The blood pressure outcome analytic subgroup included 1096 participants (n = 304 HEU), the total cholesterol and high-density lipoprotein cholesterol subgroup 1301 participants (n = 385 HEU), and the low-density lipoprotein cholesterol, TG, and Homeostatic Model Assessment-Insulin Resistance subgroup 271 (n = 83 HEU). After adjustment, obese HEU youth had a higher prevalence of systolic and diastolic hypertension [PR = 3.34, 95% confidence interval (CI): 2.48 to 4.50; PR = 2.04, 95% CI: 1.18 to 3.52, respectively], but lower prevalence of insulin resistance (PR = 0.67, 95% CI: 0.54 to 0.85) and hypercholesterolemia (PR = 0.67, 95% CI: 0.44 to 1.01) compared with obese NHANES youth.

CONCLUSIONS

In the United States, obese HEU youth seem to have an increased risk of hypertension, but lower risk of insulin resistance and hypercholesterolemia, compared with a general obese pediatric population. Monitoring for cardiovascular morbidity in adulthood may be warranted in HEU children.

Vascular Health of Children Conceived via In Vitro Fertilization

OBJECTIVE

To evaluate whether in vitro fertilization (IVF) has an effect on the cardiovascular health of offspring.

STUDY DESIGN

This was a cross-sectional pilot study. We performed vascular health assessment for 17 children aged 10-14 years who were conceived via IVF with autologous oocytes at Stanford University. Carotid artery ultrasound evaluated intima-media thickness and stiffness, carotid-femoral pulse wave velocity determined segmental arterial stiffness, and endothelial pulse amplitude testing assessed endothelial function. We compared IVF offspring with control adolescents assessed in the same laboratory, with all comparisons adjusted for age, sex, and race/ethnicity.

RESULTS

All participants had normal body mass index and blood pressure. Compared with controls, IVF children had thicker common carotid artery intima-media thickness (0.44 ± 0.03 mm vs 0.38 ± 0.03 mm; P < .01), higher elastic modulus (395.29 ± 185.33 mm Hg vs 242.79 ± 37.69 mm Hg; P = .01), higher βstiffness (2.65 ± 0.38 vs 2.28 ± 0.23; P < .01), and higher peak velocity (142.29 ± 31.62 cm/s vs 117.71 ± 32.69 cm/s; P = .04). The mean endothelial pulse amplitude testing reactive hyperemia index was not significantly different between IVF and controls. The mean pulse wave velocity was 4.69 ± 0.51 m/s compared with the controls 4.60 ± 0.57 m/s (P = .11), with 8 (47%) having abnormal values.

CONCLUSION

In an assessment of endothelial function and arterial properties of children conceived via IVF, we found that children conceived via IVF seem to have evidence of abnormal vascular health. Further studies with larger sample size and long-term follow-up are warranted.

Natural History of Atherosclerosis and Abdominal Aortic Intima-Media Thickness: Rationale, Evidence, and Best Practice for Detection of Atherosclerosis in the Young

Atherosclerosis underlies most myocardial infarctions and ischemic strokes. The timing of onset and the rate of progression of atherosclerosis differ between individuals and among arterial sites. Physical manifestations of atherosclerosis may begin in early life, particularly in the abdominal aorta. Measurement of the abdominal aortic intima-media thickness by external ultrasound is a non-invasive methodology for quantifying the extent and severity of early atherosclerosis in children, adolescents, and young adults. This review provides an evidence-based rationale for the assessment of abdominal aortic intima-media thickness-particularly as an age-appropriate methodology for studying the natural history of atherosclerosis in the young in comparison to other methodologies-establishes best practice methods for assessing abdominal aortic intima-media thickness, and identifies key gaps in the literature, including those that will identify the clinical relevance of this measure.

Ambulatory Blood Pressure Monitoring in Pediatrics

PURPOSE OF REVIEW

This is a review of ambulatory blood pressure monitoring (ABPM) use in pediatrics, summarizing current knowledge and uses of ABPM.

RECENT FINDINGS

Updated guidelines from the American Academy of Pediatrics have emphasized the value of ABPM. ABPM is necessary to diagnose white coat hypertension, masked hypertension, and nocturnal hypertension associated with specific conditions. There is growing evidence that ABPM may be useful in these populations. ABPM has been demonstrated to be more predictive of end-organ damage in pediatric hypertension compared to office blood pressure. ABPM is an important tool in the diagnosis and management of pediatric hypertension. Routine use of ABPM could potentially prevent early cardiovascular morbidity and mortality in a wide variety of populations.

Predictors and Consequences of Pediatric Hypertension: Have Advanced Echocardiography and Vascular Testing Arrived?

PURPOSE OF REVIEW

Pediatric hypertension is relatively common and associated with future adult hypertension. Elevated blood pressure in youth predicts future adult cardiovascular disease and blood pressure control can prevent progression of pediatric kidney disease. However, pediatric blood pressure is highly variable within a given child and among children in a population.

RECENT FINDINGS

Therefore, modalities to index aggregate and cumulative blood pressure status are of potential benefit in identifying youth in danger of progression from a risk factor of subclinical phenotypic alteration to clinically apparent event. In this review, we advocate for the health risk stratification roles of echocardiographically assessed cardiac remodeling, arterial stiffness assessment, and assessment by ultrasound of arterial thickening in children and adolescents with hypertension.

Disaster-related trauma and blood pressure among young children: a follow-up study after Great East Japan earthquake

The 11 March 2011 earthquake and tsunami in Japan resulted in ~19,000 lost lives and the displacement of nearly a quarter million people owing to extensive property damage and evacuation from the nuclear meltdown in Fukushima. We sought to prospectively examine whether exposure to disaster-related trauma affected blood pressure levels among young children. We sampled children in three affected prefectures (Miyagi, Fukushima, Iwate) and one unaffected prefecture (Mie). The participants (mean age 6.6 years) and their caregivers answered a baseline survey (N = 320) and a follow-up survey 4 years after the earthquake (N = 227, follow-up rate 71%). Disaster-related trauma was assessed at the baseline, and blood pressure measurements were taken at the follow-up. We converted blood pressure data into age/sex/height-specific z-scores. In linear regression models, we controlled for body mass index, income, age, sex, and housing situation (living in the same house as before the disaster, in a shelter, or in a new house). The number of traumatic experiences was related to diastolic blood pressure in a dose-dependent manner but was not related to systolic blood pressure. Children reporting four or more traumatic experiences had marginally significant elevated diastolic blood pressure (β = 0.43, p = 0.059). Among specific types of disaster trauma, witnessing a fire was significantly related to higher diastolic blood pressure (β = 0.60, p = 0.009). In conclusion, disaster-related trauma was associated with higher diastolic blood pressure among young children 4 years after the traumatic events.

Ambulatory blood pressure monitoring tolerability and blood pressure status in adolescents: the SHIP AHOY study

BACKGROUND

Ambulatory blood pressure monitoring (ABPM) provides a more precise assessment of blood pressure (BP) status than clinic BP and is currently recommended in the evaluation of elevated BP in children and adolescents. Yet, ABPM can be uncomfortable for patients and cumbersome to perform.

OBJECTIVE

Evaluation of the tolerability to ABPM in 232 adolescent participants (median age: 15.7 years, 64% white, 16% Hispanic, 53% male) in the Study of Hypertension In Pediatrics Adult Hypertension Onset in Youth and its potential effects on ABPM results.

PARTICIPANTS AND METHODS

Ambulatory BP status (normal vs. hypertension) was determined by sex and height-specific pediatric cut-points. Participants were asked to rank their wake and sleep tolerability to ABPM from 1 (most tolerant) to 10 (least tolerant); those with tolerability score of at least 8 were considered ABPM intolerant.

RESULTS

Forty-three (19%) participants had wake ambulatory hypertension (HTN), 42 (18%) had sleep ambulatory HTN, and 64 (28%) had overall (wake and/or sleep) ambulatory HTN. Forty (17%) participants were intolerant to ABPM during wake hours and 58 (25%) were intolerant during sleep. ABPM intolerance during wake (but not sleep) hours was independently associated with wake (odds ratio: 2.34, 95% confidence interval: 1.01-5.39) and overall (odds ratio: 2.94, 95% confidence interval: 1.21-7.18) ambulatory HTN.

CONCLUSION

Poor tolerability to ABPM is associated with a higher prevalence of ambulatory HTN in adolescents, and should be taken into consideration at time of ABPM interpretation.

Pediatric Hypertension

The prevalence of elevated blood pressure and hypertension in children and adolescents has increased over the past decade. This trend is most likely related to increases in primary hypertension associated with increasing obesity rates in children. Lifestyle as well as genetics play a significant role in the development of primary hypertension. Hypertension in children and adolescents is under-recognized and undertreated. The 2017 Revised Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents aimed to create new normative blood pressure tables using data from healthy weight children, meaning between the 5th and 85th percentile per the Centers for Disease Control and Prevention. Another important objective was to simplify normative data to ease screening and detection of elevated blood pressures. The consequences of chronic hypertension are significant, with its major affect being in poor cardiovascular health outcomes both in childhood and early adulthood. Challenges to detection and adequate treatment should be overcome with continued education and awareness to prevent the long-term effects of uncontrolled hypertension that starts in childhood. [Pediatr Ann. 2018;47(12):e499-e503.].

Insulin metabolism markers are predictors of subclinical atherosclerosis among overweight and obese children and adolescents

BACKGROUND

To investigate the association between markers of insulin metabolism and carotid intima-media thickness(cIMT) among overweight and obese children and adolescents.

METHODS

A total of 378 children and adolescents aged from 6 to 13 years, with WHO body mass index Z-Scores ≥2 were enrolled in this study. We measured fasting serum insulin and glucose, conducted a homeostatic model assessment of insulin resistance(HOMA-IR), and calculated the quantitative insulin sensitivity check index(QUICKI). Carotid intima-media thickness was measured in the common carotid artery with high-resolution ultrasonography.

RESULTS

The study participants consisted of 198 boys and 180 girls with a mean(±SD) age of 9.3 ± 1.7 years, 18.3% being pre-pubertal. In boys, after controlling for confounders, a one-SD increase in fasting insulin and HOMA-IR were associated with 0.351 mm(P < 0.001) and 0.350 mm(P < 0.001) increases in cIMT, respectively. However, a one-SD increase in QUICKI was associated with a - 0.305 mm(P = 0.001) decrease in cIMT. When categorizing into tertiles, a one-SD increase in fasting insulin and HOMA-IR were associated with 87 and 81% increases in the odds of higher categories of cIMT(both P < 0.05). However, a one-SD increase in QUICKI was associated with 37% lower odds of higher categories of cIMT(P = 0.022). No significant associations were found among girls.

CONCLUSION

This study demonstrated that insulin resistance and sensitivity markers were independent predictors of cIMT in overweight and obese boys, but not in girls, highlighting the importance of chronically elevated insulin levels for predisposing these boys to alterations in their vascular structure.

Prediction of Ambulatory Hypertension Based on Clinic Blood Pressure Percentile in Adolescents

Ambulatory blood pressure (BP) monitoring provides a more precise measure of BP status than clinic BP and is currently recommended in the evaluation of high BP in children and adolescents. However, ambulatory BP monitoring may not always be available. Our aim was to determine the clinic BP percentile most likely to predict ambulatory hypertension. We evaluated clinic and ambulatory BP in 247 adolescents (median age, 15.7 years; 63% white; 54% male). Clinic BP percentile (based on the fourth report and the 2017 American Academy of Pediatrics clinical practice guidelines) and ambulatory BP status (normal versus hypertension) were determined by age-, sex-, and height-specific cut points. Sensitivity and specificity of different clinic BP percentiles and cutoffs to predict ambulatory hypertension were calculated. Forty (16%) and 67 (27%) patients had systolic hypertension based on the fourth report and the 2017 guidelines, respectively, whereas 38 (15%) had wake ambulatory systolic hypertension. The prevalence of ambulatory wake systolic hypertension increased across clinic systolic BP percentiles, from 3% when clinic systolic BP was <50th percentile to 41% when ≥95th percentile. The 2017 guidelines' 85th systolic percentile had similar sensitivity (86.8%) and better specificity (57.4% versus 48.1%) than elevated BP (≥90th percentile or ≥120 mm Hg) to diagnose ambulatory hypertension. When evaluating adolescents for hypertension, 2017 guidelines' clinic systolic 85th percentile may be the optimal threshold at which to perform ambulatory BP monitoring.