Hypertension in adolescents
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: {{}} José Eduardo Riceto Loyola Junior, M.D.[2]
Synonyms and keywords:
Overview
Hypertension is one of the major risk factor for cardiovascular diseases. It is often associated with adverse cardiac and vascular outcomes. Hypertension in pediatric age group often leads to development of cardiovascular compromises for the patient, such as atherosclerotic plaques development and renal function loss in the adulthood. To make matters worse, pediatric hypertension is greatly underdiagnosed due to difficulty in measurement of blood pressure in children and the need to refer to detailed tables of normative values. Thus, cautious monitoring, early diagnosis and treatment of hypertension in children is critical to prevent disease progression.
Classification
Pediatric hypertension may be classified according to AAP (American Academic of Pediatrics):[1]
| Age<13 years | Age>=13 years | |
|---|---|---|
|
<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:[3]
- 1. Primary hypertension - No specific cause known
- 2. Secondary hypertension - Common causes includes:[4]
- Renal diseases
- Renal artery stenosis
- Obstructive sleep apnea[5]
- Related to drugs - glucocorticoids, CNS stimulants
- Congenital adrenal hyperplasia
- Pheochromocytoma
- Hyperthyroidism
- Coarctation of the aorta
Common causes of pediatric hypertension by pediatric age group
These conditions are displayed in order of prevalence[6][7][8]
One to six years:
- Renal parenchymal disease; renal vascular disease; endocrine causes; coarctation of the aorta; essential hypertension
Six to twelve years:
- Renal parenchymal disease; essential hypertension; renal vascular disease; endocrine causes; coarctation of the aorta; iatrogenic illness
Twelve to eighteen years
- Essential hypertension; iatrogenic illness; renal parenchymal disease; renal vascular disease; endocrine causes; coarctation of the aorta
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:
- Obesity
- Obstructive sleep apnea
- Diabetes
- Premature birth
- Chronic kidney disease
- Congenital heart disease
- Dyslipidemia
- Family history of hypertension
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:[9]
- 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. [10]
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). [11]
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.[12]
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.[13]
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
- ↑ Weaver DJ (2019). "Pediatric Hypertension: Review of Updated Guidelines". Pediatr Rev. 40 (7): 354–358. doi:10.1542/pir.2018-0014. PMID 31263043.
- ↑ Hypertension. In: Wikipedia [Internet]. 2021 [cited 2021 Jun 10]. Available from: https://en.wikipedia.org/w/index.php?title=Hypertension&oldid=1027062289.
- ↑ 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
- ↑ Friedman K, Wallis T, Maloney KW, et al. An unusual cause of pediatric hypertension. J Pediatr 2007; 151:206.
- ↑ Marcus CL, Greene MG, Carroll JL. Blood pressure in children with obstructive sleep apnea. Am J Respir Crit Care Med 1998; 157:1098
- ↑ Flynn JT (2001). "Evaluation and management of hypertension in childhood". Prog Pediatr Cardiol. 12 (2): 177–188. doi:10.1016/s1058-9813(00)00071-0. PMID 11223345.
- ↑ Bartosh SM, Aronson AJ (1999). "Childhood hypertension. An update on etiology, diagnosis, and treatment". Pediatr Clin North Am. 46 (2): 235–52. doi:10.1016/s0031-3955(05)70115-2. PMID 10218072.
- ↑ Flynn JT (2005). "Hypertension in adolescents". Adolesc Med Clin. 16 (1): 11–29. doi:10.1016/j.admecli.2004.10.002. PMID 15844381.
- ↑ 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..
- ↑ 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.
- ↑ 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.
- ↑ 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..
- ↑ 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.