PEDIATRIC HYPERTENSION - SC Chapter of the American ... · Pediatric Hypertension Can we still blame the kidney? A primary care problem? Objectives/Questions How do we define and

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Robert C. Holleman, Jr., MDAssociate Professor of Clinical PediatricsPediatric Nephrology and Hypertension

Prisma Health/USC - Midlands

PEDIATRIC HYPERTENSION

2019 SCAAP Meeting

Disclosures

I have no financial or industry relationships to disclose

I will not be discussing any off lable medications

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Pediatric Hypertension

Can we still blame the kidney?

A primary care problem?

Objectives/Questions

How do we define and stage HTN in children and adolescents?

Who should be screened and how often?

What are the most common causes of pediatric HTN?

What is the appropriate diagnostic plan?

When do we treat with medication and what drugs do we choose?

What is the utility of 24hr ambulatory BP monitoring?

Review the 2017 Clinical Practice Guideline

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Pediatrics. 2017;140(3):e20171904

2017 Clinical Practice Guideline

◆ Update to the 2004 “Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents.”

◆ 17 member subcommittee◆ Endorsed by the American Heart Association◆ 8 significant changes, 30 key action statements

and 27 additional recommendations published in a 72 page document

Flynn JT et al. Pediatrics. 2017;140(3):e20171904

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2017 Clinical Practice Guideline

1) Replacement of the term “prehypertension” with “elevated blood pressure”

2) New normative BP tables (normal weight children)3) Simplified screening table4) Simplified BP classification for adolescents > 13 yrs5) More limited screening recommendation6) Streamlined evaluation and management strategies7) Expanded role for ambulatory BP monitoring8) Revised recommendation on echocardiography

8 Significant changes:


Epidemiology

◆ Overall prevalence of pediatric HTN is 3.5%

◆ Prevalence of elevated BP is 2.2-3.5%

◆ Higher in minority populations

◆ ♂ > ♀

◆ BP BMI

◆ Essential HTN is the most prevalent form

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Epidemiology

◆ Overweight and Obese: 4-25%

◆ Sleep Disordered Breathing: 4-14%

◆ Chronic Kidney Disease: 50%

◆ Preterm Birth/Low Birth Weight: 7%

Increased prevalence in select populations:


Epidemiology: Risk Factors

Family History

Low birth weight

Obesity Race

Diet – Na intake

Stress

Smoking Physical Activity

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Blood Pressure Measurement

◆ Cuff size critical◆ Comfort/Cooperation◆ At rest for 3-5 minutes◆ Clothing out of the way◆ Right arm, heart level◆ Back supported, feet on floor◆ At least 2 readings

Patient Issues

Blood Pressure Measurement

◆ Cuff size critical

◆ Calibration and upkeep

◆ Auscultatory

- “Gold standard”

- K1 = SBP, K5 = DBP

◆ Oscillometric

◆ Observer bias

Technical Issues

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◆ Bladder width >40% mid arm circumference

◆ Bladder length 80-100% mid arm circumference

◆ Lower edge of cuff ~2cm above olecranon fossa

◆ For severe obesity, use thigh cuff

How do we define Hypertension?

◆ BP level associated with increased morbidity and mortality

◆ Method of measurement- Casual (office) BP

- 24hr ambulatory BP (BP load)

◆ Large pediatric variation by age, size and sex

◆ Task Force data

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Definition of Hypertension

Designation Kids age 1-12 yearsKids age 13 and

older*

Normal BP < 90th %tile < 120/80

Elevated BP90th%tile to < 95th %tile or

120/<80 to < 95th %tile (whichever is lower)

120/<80 to 129/<80

Stage 1 HTN>95th%tile to <95th%tile + 12

or 130/80 to 139/89 (whichever is lower)

130/80 to 139/89

Stage 2 HTN>95th%tile + 12 or > 140/90

(whichever is lower)> 140/90

*Consistent with American Heart Association and American College of Cardiology guidelines

What is “elevated blood pressure?”

◆ Replaces the term “prehypertension” ◆ BP > 90th %tile but < 95th %tile◆ Adolescents with BP 120-129/75-79◆ Implement healthy lifestyle changes and

identify other cardiovascular disease risk factors

◆ Recheck BP in 6 months◆ If BP remains elevated after 12 months ABPM

is recommended◆ At risk for future HTN so follow up is key

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Diagnosis: Fourth Taskforce

AAP HTN Calculator

https://www.mdcalc.com/aap-pediatric-hypertension-guidelines#next-steps

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AAP HTN Calculator

https://www.mdcalc.com/aap-pediatric-hypertension-guidelines#next-steps

Simplified BP TableAge Boys SBP Boys DBP Girls SBP Girls DBP

1 98 52 98 54

2 100 55 101 58

3 101 58 102 60

4 102 60 103 62

5 103 63 104 64

6 105 66 105 67

7 106 68 106 68

8 107 69 107 69

9 107 70 108 70

10 108 72 109 72

11 110 74 111 74

12 113 75 114 75

>13 120 80 120 80

Based on the 90th %tile BP for age at the 5th

%tile for heightDesigned as a screening tool only

Determines which patients need repeat measurements

Provides a negative predictive value of >99%

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BP Screening: why it’s important

◆ HTN is the most common primary diagnosis in the U.S. with healthcare costs in the billions

◆ High BP in adults is an independent risk factor for the development of cardiovascular disease, stroke, and chronic kidney disease

◆ More than 7 million premature deaths worldwide annually in adults attributable to HTN

◆ HTN accounts for 40% of cardiovascular mortality, more than any other risk factor including smoking

BP Screening: why it’s important◆ BP tracking: childhood BP predicts adult BP

✓ Childhood HTN is the strongest predictor of adult HTN

✓ BP at the 90th %tile in childhood increases risk of adult HTN x 2.4

◆ Childhood HTN is associated with increased carotid intima-media thickness, endothelial dysfunction and increased vascular stiffness markers for adult atherosclerosis

◆ The rationale for childhood BP screening as an important strategy for increasing health and decreasing cardiovascular mortality in adults has been endorsed by:

✓ American Academy of Pediatrics ✓ European Society of Hypertension

✓ American Heart Association ✓ National Heart Lung and Blood Institute

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BP Screening: current practice

Type of Visit 2000-2009 2000-2001 2008-2009

All Visits 35% 26% 41%

Preventive Care Visits 67% 51% 71%

Preventive Care Visits + Overweight/Obese

84% 71% 81%

Hypertension Screening During Ambulatory Pediatric Visits in the United States, 2000-2009

- Shapiro DJ et al, Pediatrics, 2012

Data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey

◆ 93,534 ambulatory visits for children age 3 to 18 sampled◆ BP screening more likely in older kids and kids who were overweight/obese◆ Non factors in screening frequency included: race, gender, region, practice

setting and use of an EMR

Who should be screened and how?

◆ All children > 3 years of age annually

◆ Kids with obesity, kidney disease, diabetes, aortic arch obstruction or coarctation, or those on medications known to increase BP should be screened at ALL office visits

◆ Preferred method is auscultation with an age/size appropriate cuff

◆ If initial BP >90th %tile, take 2 additional readings and average them to determine BP stage


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Conditions requiring BP screening prior to age 3 years

◆ History of prematurity (<32 wks), SGA, low birth weight, or complicated NICU stay

◆ Congenital heart, renal, or urologic disease

◆ Recurrent UTIs, hematuria, proteinuria

◆ Solid organ/bone marrow transplant or malignancy

◆ Treatment with drugs known to cause BP

◆ Systemic disease associated with HTN

◆ Evidence of increased intracranial pressure


Pathophysiology

Hormonal regulation

Genetics Environment

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Etiology of Pediatric HTN

◆ No identifiable cause

◆ Age > 6 years

◆ Positive family history

◆ Closely related to BMI

◆ Negative history

◆ Stress sensitive

◆ Less severe*

◆ Systolic*

◆ Age < 6 years

◆ Lack of co-morbidities or family history

◆ Signs/symptoms more likely

◆ History suggestive

◆ More severe*

◆ Diastolic*

ESSENTIAL HTN SECONDARY HTN

*Not reliable, a loose association

Obesity related HTN

◆ 35-50% of hypertensive adolescents are obese◆ The relationship between BP and weight begins

as early as age 5yrs◆ HTN is three times more common in obese

children◆ Obesity is an independent risk

factor for other cardiovascular morbidity ● insulin resistance/type II DM● dyslipidemia● LVH

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Obesity related HTN

The Perils of Insulin

SNS

Altered

vascular

reactivity

Na

retention RAS

HYPERTENSION

Renal Causes of Secondary HTN

◆ Parenchymal Disease (70-80%) Reflux nephropathy/scarring Obstructive uropathy

Inherited disease (PKD, TS) Dysplasia/hypoplasia

Chronic glomerular disease

◆ Renovascular Disease (5-10%) RA stenosis (FMD, NF, Williams) RA/RV thrombosis

Vascular malformation (AVM) External compression

◆ Chronic or End Stage Kidney Disease

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Other Causes of Secondary HTN

◆ Cardiovascular Coarctation Vasculitis

◆ Endocrine Catecholamine excess (the “omas”)

Corticosteroid excess (CAH, Cushing, hyperaldo,AME)

Hypercalcemia (Hyperparathyroidism, Williams)

Hyper and hypothyroidism

Other Causes of Secondary HTN◆ Neurologic

Central ( ICP, seizures, spinal cord lesions)

Peripheral (Guillain-Barre, dysautonomia)

◆ Drugs Caffeine Nicotine

Steroids Decongestants

Cocaine Methamphetamine

-agonists ADHD meds

OCPs

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Most Common Causes By Age

◆ RA thrombosis

◆ RV thrombosis

◆ Congenital uropathy

◆ Coarctation

◆ RA stenosis

◆ BPD

◆ Renal parenchymal dz

◆ RA stenosis

◆ Coarctation

◆ Medications

◆ Endocrine causes

◆ Essential HTN

Decreasing frequency

NEONATE FIRST 6 YEARS

Most Common Causes By Age


◆ Essential HTN

◆ RA stenosis


◆ Essential HTN


◆ Substance abuse

◆ Teen prednancy


Decreasing frequency

6-10 YEARS ADOLESCENCE

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Primary vs Secondary HTN

Adapted from Flynn, J. Pediatr Nephrol, Vol 28, 2013

Genetic HTN can be more than just “essential” disease

◆ Advances in positional cloning have led to the identification of specific monogenic forms of HTN

◆ Suspect in kids with difficult to control HTN and a strong family history of early onset severe HTN or those with K+ abnormalities

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Monogenic Forms of HTN

◆ Glucocorticoid-remediable aldosteronism

AD; chromosome 8; K+; renin; aldo

◆ Apparent mineralocorticoid excess

AR; chromosome 16; K+; renin; aldo

◆ Liddle syndrome

AD; chromosome 16; K+; renin; aldo

◆ Gordon syndrome (pseudohypoaldo type II)

AD; chromosomes 1, 17, and 12; K+; renin

Evaluating the Hypertensive Child

◆ Is the HTN real and sustained?

◆ Is there a definable cause or a clue to secondary disease?

◆ Are there other cardiovascular risk factors?

Consider the following questions:

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Step 1 ➢ History

◆ Perinatal complications including prematurity/birth weight

◆ UTIs or voiding dysfunction

◆ Sleep disturbances

◆ Nutrition and physical activity

◆ Growth and development

◆ Medications/Drugs

◆ Psychosocial history

◆ Complete ROS

◆ Complete family history

Hypertensive symptoms

Most pediatric patients with hypertension are asymptomatic

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Meds and Drugs Associated with Elevated BP

◆ Over the Counter Drugs◆ Decongestants, Caffeine, NSAIDs, Herbal and

Nutritional supplements

◆ Prescription Drugs◆ ADHD medications

◆ Contraceptives

◆ Steroids

◆ TCAs

◆ Illicit Drugs◆ Cocaine

◆ Amphetamines/Methamphetamines

Step 2 ➢ Physical Exam

◆ Growth curve, BMI

◆ Other vital signs

◆ Dysmorphic features

◆ Fundoscopic changes

◆ Skin findings – striae, neurocutaneous or vasculitic lesions, acanthosis

◆ Genitalia – ambiguous, virilized

◆ Peripheral pulses, LE BPs, bruits

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Step 3 ➢ Staged Work UP

◆ Blood work◆ Chemistry Panel and lipid profile

◆ Based on BMI/risks consider HgbA1c and LFTs

◆ Urinalysis

◆ Renal Ultrasound◆ If <6yrs, history of prematurity or UTIs, or abnormal

U/A or renal function

◆ ECHO◆ Recommended at time of consideration of drug tx

PHASE 1

Staged Work Up

◆ Further imaging based on phase 1 work up◆ VCUG, MRA/CTA, Angiography

◆ Urine Pro:Cr or 24hr urine protein◆ Urine Drug Screen◆ Thyroid function tests◆ Renin*, Aldosterone*◆ Plasma and urine steroids

PHASE 2 – if indicated

* Consider in phase 1 if high suspicion of 2º HTN, infant/toddler, or if abnormal electrolytes

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Cardiac Diagnostics◆ Prevalence of left ventricular hypertrophy (LVH) in

childhood hypertension is 30-40%◆ HTN LVH Adverse CVD Outcomes◆ EKG is NOT recommended◆ ECHO should be done at time of initiation of

medication◆ ECHO should be repeated every 6-12 months for

kids with documented LVH or poorly controlled HTN with normal initial ECHO

◆ LVH is defined as:◆ LV mass index > 51g/m2.7 for all kids > 8yrs◆ LV mass > 115g/BSA boys, > 95g/BSA girls

The Therapeutic Plan

Non-pharmacologic tx Good for everyone

Multifaceted

AntihypertensivesWho gets them?

Which ones?

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Goals of Therapy

◆ Reduce the risk of target organ damage◆ Reduce the risk of adult HTN and CVD◆ Achieve optimal BP control

◆ Target BP < 90th %tile for younger children◆ Target BP <130/80 for adolescents > 13 yrs

Non-pharmacologic therapy“TLC”

Wt Loss

Lifestylemodification

Stressmanagement

Exercise

Diet

Blood Pressure

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Dietary Interventions◆ Na+ restriction (< 2 gm/day)

greater “salt sensitivity” in African Americans and obese pts

◆ Dietary Approaches to Stop HTN or “DASH” more fruits, veggies, whole grains, low fat dairy

theoretical benefit from K+, Ca++, and Mg++

◆ Avoid caffeine/energy drinks

◆ Address dietary cholesterol and fat as well as foods with high glycemic load when appropriate

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The Salt Dilemma◆ Difficulty controlling sodium content of

meals outside the home

◆ Difficultly interpreting nutrition labels

◆ Difficulty identifying suitable low Na snacks

◆ Resources often limited

◆ Recommended daily intake:◆ 1-3 years < 1000mg

◆ 4-8 years < 1200mg

◆ Older kids < 1500mg

Fast Food◆ It’s not just fast…its cheap, convenient and without

portion control

◆ Extremely high in sodium

◆ McDonald’s◆ Grilled Chicken Classic 1240mg

◆ Chicken McNuggets 670mg

◆ Pizza Hut◆ 12” thin crust cheese pizza 490mg

◆ KFC◆ Oven Roasted Twister 1390mg

◆ Subway◆ 6” Ham sub 1280mg

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Benefits of the “other salts”

◆ Potassium, magnesium and calcium have a beneficial effect on BP

◆ Potassium leads to suppression of renin

The Benefits of Exercise

◆ sympathetic tone and SVR

◆ Contributes to weight loss

◆ Lowers insulin levels

◆ 30-60 min daily of moderate to strenuous activity

◆ For most kids with HTN…”it’s ok to play”

Lowers blood pressure

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Treatment PlanRisk Assessment

◆ Family History:

- HTN, CVD, CVA

◆ Obesity

◆ Dyslipidemia

◆ Insulin resistance

◆ LVH

◆ Proteinuria or microalbuminuria

◆ Chronic disease:- DM, CKD

Co-Morbid Risk Factors

Target Organ Dz (TOD) Chronic Disease

Treatment PlanIndications to Rx

◆ Stage 1 HTN that has failed lifestyle change after 3-6 months

◆ Stage 2 HTN

◆ Symptomatic HTN

◆ Presence of end organ damage

◆ Kids with chronic disease (DM, CKD)

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Drug Therapy - Choices

◆ ACE inhibitors

◆ Ca channel blockers

◆ Diuretics

◆ Angiotensin receptor blockers (ARBs)

◆ Sympathetic antagonists - and/or

◆ Other

Angiotensin Converting Enzyme Inhibitors (ACEI)

◆ Mechanism: Ang I Ang II

◆ Adverse effects: cough, hypotension, GFR, angioedema, K+, marrow suppression

◆ Contraindications: pregnancy, AKI, bilateral renal artery stenosis, volume depletion

◆ The “prils”: enalapril, lisinopril, captopril

◆ Benefits: very effective, well tolerated, reno-protective, proteinuria

◆ Other: some resistance in African Americans

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Ca Channel Blockers

◆ Mechanism: block influx of Ca++ into vascular smooth muscle cells ➢ decrease vascular resistance

◆ Adverse effects: HA, flushing, hypotension, edema, gingival hypertrophy

◆ Short acting: safe when used with caution, isradipine vs. nifedipine

◆ Long acting: amlodipine, nifedipine XL◆ Benefits: good peds experience, well

tolerated, convenient dosing forms available

Diuretics

◆ Mechanism: block renal solute reabsorption ➢ decreased IV volume

◆ Adverse effects: K, Na, alkalosis, enuresis, hyperlipidemia, hypercalciuria, hyperglycemia

◆ Diverse group of drugs: THIAZIDES #1 for chronic HTN; useful as 2nd agent or occasionally as monotherapy; Chlorothiazide, HCTZ LOOP agents acute HTN in certain settings, refractory volume overload; Furosemide, Bumetanide K+ SPARING weak diuretics; use for mineralocorticoid excess or as 2nd diuretic if hypoK; Spironolactone, Amiloride

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Angiotensin Receptor Blockers

◆ Mechanism: Prevents binding of ang II to the type I receptor (vascular smooth muscle and adrenal gland) ➢

vasoconstriction aldosterone◆ Adverse effects: same as ACEI except

cough◆ Contraindications: same as ACEI◆ The “tans”: Losartan, Irbesartan, Valsartan◆ General: less pediatric experience;

adjunctive antiproteinuric effect with ACEI

Other Drugs

◆ Beta blockers

◆ Alpha blockers

◆ Clonidine

◆ Hydralazine

◆ Minoxidil

These drugs are NOT first line agents

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Remember these drugs…

Amlodipine Enalapril

Starting dose 0.1mg/kg (max 5mg) 0.1mg/kg (max 5mg)

Interval Daily - BID Daily -BID

Suspension 1mg/ml 1mg/ml

Tablet strength 2.5, 5, 10 2.5, 5, 10, 20

Drug Therapy Strategies◆ If therapy needed in young child prior to

completion of work-up

Ca channel blocker◆ For patients with proteinuria, renal dz or

diabetes, or evidence of renovascularhypertension

ACE Inhibitor◆ Partially controlled BP on good dose Ca channel

blocker or ACEI

HCTZ

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Therapy Take Home Points◆ Ca channel blockers are generally the safest

choice when dosed appropriately

◆ ACEIs are not to be feared and have additional benefits

◆ Diuretics are making a comeback in pediatrics particularly in salt sensitive essential disease

◆ -blockers have more side effects and should be reserved for difficult to control HTN

BP Monitoring

Medication prescribed?

Follow q 4-6 weeks until goal

BP achieved

Follow q 3-4 months

Follow q 3-6 months

Yes No

Then

Assess compliance at every visit

DietExercise

Medications

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Hypertension and the Athlete

◆ Though existing guidelines have conflicting recommendations, there is no evidence that exercising while hypertensive increases risk of sudden death

◆ Physical fitness is associated with lower BP and lower all cause mortality

◆ More caution attached to high static sports: weight lifting, boxing, wrestling


Hypertension and the Athlete

◆ Prior to participation in competitive sports, children and adolescents with HTN should be assessed for target organ effects and risk

◆ Children and adolescents with HTN should have a BP below stage 2 cutoffs before participating

◆ Hypertensive children and adolescents with LVH should refrain from competitive sports until BP normalized


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24hr Ambulatory BP Monitoring

◆ More accurate assessment of blood pressure

◆ Identifies “white coat HTN” saving $$ in work-up

◆ BP readings q 20-30 min

◆ Assess nocturnal dipping

◆ HTN determined by % of readings > 95th %tile or the “blood pressure load”

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Ambulatory BP Monitoring◆ Results track better than casual readings ➢

better predictor of adult HTN

◆ Results better predict the presence of TOD

◆ Loss or blunting of nocturnal dipping correlates with microalbuminuria in kids with normal daytime casual BP and is early indicator of HTN

◆ BP load < 25% considered normal; load > 40% indicates HTN

◆ Estimated that up to 50% of kids with elevated office BP have white coat HTN

Masked Hypertension

◆ Normal office readings with abnormal ABPM

◆ Prevalence as high as 5-6% in unselected pediatric population

◆ Growing evidence of significant risk for target organ disease

◆ High risk groups include: obesity, CKD, and repaired coarctation

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There’s an App For That!

MyTherapy BP Companion

Pediatric Nephrology Program University of S.C. School of Medicine

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Documents

PEDIATRIC HYPERTENSION - SC Chapter of the American ... · Pediatric Hypertension Can we still blame the kidney? A primary care problem? Objectives/Questions How do we define and