Hypertension in adolescents
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.
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.
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:
- Renal diseases
- Renal artery stenosis
- Obstructive sleep Apnea
- Related to drugs - glucocorticoids, CNS stimulant
- Congenital adrenal hyperplasia
- Pheochromocytoma
- Hyperthyroidism
- Coarctation of the aorta
Differentiating ((Page name)) from other Diseases
[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].
OR
[Disease name] must be differentiated from [[differential dx1], [differential dx2], and [differential dx3].
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:
- Obesity
- Obstructive sleep apnea
- Diabetes
- Premature birth
- Chronic kidney disease
- Congenital heart disease
- Dyslipidemia
- Family history of Hypertension
Screening
There is insufficient evidence to recommend routine screening for [disease/malignancy].
OR
According to the [guideline name], screening for [disease name] is not recommended.
OR
According to the [guideline name], screening for [disease name] by [test 1] is recommended every [duration] among patients with [condition 1], [condition 2], and [condition 3].
Natural History, Complications, and Prognosis
If left untreated, [#]% of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
OR
Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
OR
Prognosis is generally excellent/good/poor, and the 1/5/10-year mortality/survival rate of patients with [disease name] is approximately [#]%.
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:
- 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.
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).
Laboratory Findings
There are no diagnostic laboratory findings associated with hypertension.
Electrocardiogram
There are no ECG findings associated with [disease name].
OR
An ECG may be helpful in the diagnosis of [disease name]. Findings on an ECG suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
X-ray
There are no x-ray findings associated with [disease name].
OR
An x-ray may be helpful in the diagnosis of [disease name]. Findings on an x-ray suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
OR
There are no x-ray findings associated with [disease name]. However, an x-ray may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
Echocardiography or Ultrasound
There are no echocardiography/ultrasound findings associated with [disease name].
OR
Echocardiography/ultrasound may be helpful in the diagnosis of [disease name]. Findings on an echocardiography/ultrasound suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
OR
There are no echocardiography/ultrasound findings associated with [disease name]. However, an echocardiography/ultrasound may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
CT scan
There are no CT scan findings associated with [disease name].
OR
[Location] CT scan may be helpful in the diagnosis of [disease name]. Findings on CT scan suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
OR
There are no CT scan findings associated with [disease name]. However, a CT scan may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
MRI
There are no MRI findings associated with [disease name].
OR
[Location] MRI may be helpful in the diagnosis of [disease name]. Findings on MRI suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
OR
There are no MRI findings associated with [disease name]. However, a MRI may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
Other Imaging Findings
There are no other imaging findings associated with [disease name].
OR
[Imaging modality] may be helpful in the diagnosis of [disease name]. Findings on an [imaging modality] suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
Other Diagnostic Studies
There are no other diagnostic studies associated with [disease name].
OR
[Diagnostic study] may be helpful in the diagnosis of [disease name]. Findings suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
OR
Other diagnostic studies for [disease name] include [diagnostic study 1], which demonstrates [finding 1], [finding 2], and [finding 3], and [diagnostic study 2], which demonstrates [finding 1], [finding 2], and [finding 3].
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.