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Evaluation & Management of Hypertension

What’s new?

Dr. Jyoti Sharma

Consultant Pediatric Nephrologist
KEM Hospital, Pune
Pediatrics. 2017;140(3):e20171904

Endorsed by the American Heart Association

29/03/18 ATC, AIIMS
The normative data
 The original data was revisited and BP values of

overweight and obese (ie those with a BMI ≥85th

percentile) was excluded

 The practical effect of this change: current BP values

are lower than those in the tables of the IV Task Force

and threshold for diagnosis of elevated or high BP lower

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Definition of Hypertension

IV Task force Current Guidelines

Children and adolescents Age1-13 y
SBP/ DBP(mmHg) SBP/DBP (mmHg)
Normal < 90th centile Normal < 90th centile

Pre ≥90-<95th centile ≥90-<95th centile

hypertension Or >120/80 to Elevated BP Or > 120/80 to
<95th centile <95th centile*

* Whichever is lower
Definition of Hypertension
IV Task force Current Guidelines

SBP/ DBP(mmHg) SBP/DBP (mmHg)

Normal < 90th centile Normal < 90th centile

Pre ≥90-<95th centile Elevated BP ≥90-<95th centile

hypertension Or > 120/80 to
<95th centile*
Stage 1 95th -99th + 5 Stage 1 ≥95th - <95th + 12
mmHg Or 130/80-
Stage 2 > 99th + 5 139/89*
Stage 2 ≥ 95th + 12 or
≥140/90 *
* Whichever is lower
Definition of Hypertension contd.

Am College of Cardiology & Am Heart Association Task Force on Clin Practice Guidelines
Reference Table
Simplified Table
90th percentile
5th percentile of height

Ideal for screening BP

values requiring further

predictive value
of >99%.
Frequency of monitoring

For healthy children BP should be recorded at 3 years of age and

annually thereafter rather than at every health encounter
grade C, moderate

Children should have BP measured at every health encounter

 With obesity (BMI ≥95 percentile)
 Renal disease
 Diabetes
 Aortic arch obstruction or coarctation
 Those taking medications known to increase BP

grade C, moderate
Flags for abnormal records

Where electronic health records are used abnormal BP

records to be flagged by software so that those with elevated

BP or hypertension should be quickly brought to attention

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Patient Management on the basis of Office BP

 Streamlined recommendations for initial evaluation of a child

with office records of elevated BP or with HT

 ABPM should be performed for the confirmation of HTN

in children and adolescents with office BP measurements

(grade C, moderate recommendation)

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Evaluation and Management Elevated BP

Or > 120/80
to <95th
Evaluation and Management Stage 1 HTN
≥95th - <95th + 12 mmHg Or 130-139/ 80-89 mmHg

Evaluation and Management Stage 2 HTN
≥ 95th + 12 mmHg or ≥140/90 mmHg

If the patient is symptomatic or BP 95th percentile + 30 mm Hg or >180/120 mm Hg in an
adolescent, admission and immediate management
Ambulatory BP monitoring
 Is more accurate for the diagnosis of HTN than clinic- measured BP

hence application of ABPM is recommended, when available

 Is more predictive of future HT

 Can assist in the detection of secondary HTN ✔

 Increased LVMI and LVH correlate more strongly with ABPM

parameters than casual BP

 Routine performance should be strongly considered in children

and adolescents with high-risk conditions ✔

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High Risk Conditions
 Secondary Hypertension

 Chronic kidney Disease or structural renal abnormalities

 Diabetes mellitus: Type 1 and Type 2

 Solid organ transplant

 Sleep disordered breathing

 Repaired coarctation of Aorta

 Syndromes associated with HT eg neurofibromatosis,


 Children born prematurely

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Nocturnal BP dip in children with untreated Primary & Secondary HT
 Retrospective analysis of ambulatory BP records from 145 children

with untreated hypertension

Primary HT Secondary HT
N=45 N=100
BP dip for SBP 14% +/- 4% 8% +/- 5% ✔ P < .0001 for
BP dip for DBP 22% +/- 5% 14% +/- 7% ✔

Non dippers 11 % SBP 65% for SBP

( <10%) 0 for DBP
21% for DBP

 Children with blunted nocturnal BP dip or sustained nighttime

HT should be thoroughly investigated for an underlying cause
of HT
Seeman T, Palyzova D, Dusek J, Janda J. The J of Ped 2005,147(3):366-371
Ambulatory BP in CKD
 Regardless of apparent control of BP with office

measures, children and adolescents with CKD should

have BP assessed by ABPM at least yearly to screen
for masked hypertension

 Children or adolescents with both CKD and HT

should be treated to lower 24-hour MAP to <50th

percentile by ABPM

(grade B; strong recommendation)

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Strict Blood-Pressure Control and
Progression of Renal Failure in Children

-385 children, 3-18 y,

e GFR of 15-80 ml/min/1.73m2

- Randomized to an intensive target
(24- hour MAP <50th centile)
- or conventional target
- (24h MAP 50th to 90th centile)

All received ramipril at 6 mg/m2 /day + additional anti-HT agents when required
The primary study endpoint: 50% reduction in eGFR or progression to ESRD
The hazard ratio for progression to ESRD with the intensified BP control: 0.65 (95%CI 0.44–
0.94) compared to conventional therapy.
Results of the ESCAPE study suggest: target MAP on ambulatory BP in children with CKD <
50th percentile

ESCAPE Trial Group. N Engl J Med.2009;361(17):1639

Caveats for the Use of Ambulatory BP

 For technical reasons, ABPM may need to be limited to

children ≥5 years of age who can tolerate the procedure

 To those for whom reference data are available 120 cms

 Using a standardized approach

 With monitors that have been validated in a pediatric


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Echocardiography ….When
 At the time of initiation of pharmacologic treatment of HT

 Repeat at 6- 12-mo intervals to monitor


 In patients without LV target organ injury at initial assessment,

repeat echocardiography at yearly intervals if

 stage 2 HTN

 secondary HTN

 chronic stage 1 HTN poorly controlled

29/03/18 Grade C, moderate recommendation

Measures of Hypertensive LV target organ injury are

 LV Hypertrophy
 For children > 8 years: LV mass >51 g/m2.7(boys & girls)
 For children < 8 years: LV mass >115 g/BSA for boys
LV mass >95 g/BSA for girls

 LV wall thickness >1.4 cm is abnormal

 LV relative wall thickness > 0.42 cm indicates concentric geometry

 LV Systolic function or LV ejection fraction

Decreased LV ejection fraction <53%

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Treatment Goals
The Fourth Report: For children with uncomplicated
primary hypertension & no hypertensive target-organ
damage, the goal BP should be 95th percentile for gender,
age, and height

Current Guidelines: an optimal BP level to be achieved with

treatment is <90th percentile or <120/80 mm Hg, whichever
is lower

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Left VMI in normotensive, prehypertensive (Elevated BP) and
hypertensive children & adolescents

124 children, 5-18 y 34.1±3.4 36.8±8.4

24h ABPM and Echo P=0.71


Stabouli, Kotsis et al Pediatr Nephrol (2009) 24:1545

To Summarize
Significant changes in these guidelines

 “ Elevated blood pressure, ” replaces the term “ pre-HT”

 New normative BP tables are based on normal-weight children

 Include a simplified screening table

 A simplified BP classification in adolescents ≥ 13 years

 Streamlined recommendations on the initial evaluation and

management of abnormal BPs

 An expanded role for ambulatory BP

 Echocardiography: revised definitions and when to perform

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Professor of Pediatrics, University of
Joseph T Flynn Washington School of Medicine

Chief, Div of Nephrology at Seattle Children's

Co-chair of an AAP Committee for developing

these guidelines

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Thank You