Hypertension in adolescents

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Synonyms and Keywords:

Overview

Hypertension is one of the major risk factor for various cardiovascular diseases, often associated with adverse cardiac and vascular changes. Hypertension in pediatric age group often leads to development of cardiovascular event, atherosclerotic burden and renal diseases in the adulthood. So, the cautious monitoring, early diagnosis and treatment of hypertension in children is very important to prevent the progression of the disease. However, pediatric hypertension is greatly under-diagnosed due to difficulty in measurement of blood pressure in children and the need to refer to detailed tables of normative values. [1]

Classification

Pediatric hypertension may be classified according to AAP (American Academic of Pediatrics):

Age<13 years Age>=13 years

Normal Blood pressure

<90th percentile

<180/<90 mmhg

Elevated or High Normal Blood Pressure

90th to <95th percentile

120-129/<80 mmHg

Stage 1 Hypertension

>95th percentile to <95th percentile +12 mmHg

130-139/80-89 mmHg

Stage 2 Hypertension

>95th percentile + 12 mmHg

>140/90 mmHg

Pathophysiology

It is thought that hypertension is caused by either increased resistance to blood flow, disturbance in Kidney's salt and water handling , or abnormalities of sympathetic nervous system.[2]

Causes

Based on etiology, hypertension in children can be classified into 2 groups:

  • 1.Primary hypertension- No specific cause known
  • 2.Secondary hypertension - Common causes includes:[3]

Differentiating ((Page name)) from other Diseases

Hypertension in adolescent must be differentiated from renal diseases, secondary to drugs, adrenal diseases and hyperthyroidism.

Epidemiology and Demographics

Patients of all age groups may develop hypertension. According to WHO, an estimated 1.13 billion people worldwide have hypertension. Hypertension commonly affects individuals older than 65 years of age, especially living in low or middle income countries. In a systemic review of the global prevalence of pediatric hypertension, pre-hypertension and elevated blood pressure had a prevalence of 9.7%(95%CI 7.3-12.4), stage 1 hypertension a prevalence of 4.0% (95% CI 2.1-6.5) and stage 2 hypertension a prevalence of 1.0%(95% 0.5-1.6). Higher prevalence noted in patient who were classified as obese or overweight.

Risk Factors

Common risk factors in the development of Hypertension include:

Screening

According to the U.S. Preventive Services Task Force (USPSTF) , screening for hypertension in asymptomatic children and adolescent is not recommended.

Natural History, Complications, and Prognosis

If left untreated, children with hypertension may progress to develop atherosclerotic heart disease in adulthood, increased risk of cardiovascular disease and mortality as well as left ventricular hypertrophy.

Diagnosis

Diagnostic Study of Choice

The diagnosis of hypertension in children is based on the American Academy of pediatrics (AAP) guideline, which classify hypertension into:[5]

  • Elevated Blood Pressure
  • Stage 1 Hypertension
  • Stage 2 Hypertension

History and Symptoms

The majority of children with hypertension are asymptomatic. Common symptoms of hypertensive emergencies include headache, altered sensorium, seizures, vomiting, focal neurologic complaints and visual disturbances. [6]

Physical Examination

Common physical examination findings of hypertension include retinal vascular changes on fundoscopy, cardiac heave, and laterally displaced point of maximal intense (PMI) due to Left ventricular hypertrophy (LVH). [7]

Laboratory Findings

There are no diagnostic laboratory findings associated with hypertension. To evaluate for end-organ damage (renal), measurement of serum blood urea nitrogen (BUN), Plasma renin and aldosterone activity, creatinine, and electrolytes and urinalysis can be done.

Electrocardiogram

An ECG may be helpful in the diagnosis of hypertension. Findings on an ECG suggestive of hypertension include LVH, ST depression and T-inversion.

X-ray

An x-ray may be helpful in the diagnosis of hypertension. Findings on an x-ray suggestive of hypertension include increased cardiothoracic ratio, secondary to LVH.

Echocardiography or Ultrasound

There are no echocardiography/ultrasound findings diagnostic of hypertension. However, an echocardiography/ultrasound may be helpful in the diagnosis of complications of hypertension, which include Left ventricular hypertrophy and renovascular disease.[8]

CT scan

There are no CT scan findings associated with hypertension.

MRI

There are no MRI findings associated with hypertension.

Other Imaging Findings

There are no other imaging findings associated with hypertension.

Other Diagnostic Studies

There are no other diagnostic studies associated with hypertension.

Treatment

The AAP guideline recommends keeping systolic and diastolic pressure under 90th percentile i.e <130/80 mmHg in adolescents to prevent any cardiovascular events.

Medical Therapy

The mainstay of treatment for hypertension in adolescents is pharmacotherapy. Pharmacological therapy is reserved for those patient who has persistent hypertension despite lifestyle modification, or has stage 2 hypertension or have hypertension secondary to chronic kidney disease or diabetes. First line medication generally include angiotensin converting enzymes inhibitors (ACEIs), Angiotensinogen receptor blockers (ARBs), long acting calcium channel blockers (CCBs) and thiazide diuretics.[9]

Surgery

Surgery is not the first-line treatment option for children with hypertension. Surgery is usually reserved for children with adrenal malignancy.

Primary prevention

Effective measures for the primary prevention of primary hypertension in children include low sodium intake, maintaining appropriate body weight, and regular physical activities.

Secondary prevention

There are no established measures for the secondary prevention of hypertension in children.

References

  1. Khoury, M. and Urbina, E. M. (2021) ‘Hypertension in adolescents: diagnosis, treatment, and implications’, The Lancet Child & Adolescent Health, 5(5), pp. 357–366. doi: 10.1016/S2352-4642(20)30344-8
  2. Hypertension. In: Wikipedia [Internet]. 2021 [cited 2021 Jun 10]. Available from: https://en.wikipedia.org/w/index.php?title=Hypertension&oldid=1027062289.
  3. Friedman K, Wallis T, Maloney KW, et al. An unusual cause of pediatric hypertension. J Pediatr 2007; 151:206.
  4. Marcus CL, Greene MG, Carroll JL. Blood pressure in children with obstructive sleep apnea. Am J Respir Crit Care Med 1998; 157:1098
  5. Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics 2017; 140..
  6. Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics 2017; 140.
  7. Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics 2017; 140.
  8. Chhadia S, Cohn RA, Vural G, Donaldson JS. Renal Doppler evaluation in the child with hypertension: a reasonable screening discriminator? Pediatr Radiol 2013; 43:1549..
  9. Lurbe E, Agabiti-Rosei E, Cruickshank JK, et al. 2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents. J Hypertens 2016; 34: 1887–920.


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