Management of High Blood Pressure Management of High Blood Pressure in Children and Adolescents: in Children and Adolescents:

Recommendations of the Recommendations of the European Society of HypertensionEuropean Society of Hypertension

Empar Lurbe – Chairperson; Renata Cifkova; J Kennedy Cruickshank; Michael J Dillon; Isabel Ferreira; Cecilia Invitti; Tatiana Kuznetsova; Stephane Laurent – Ex officio; Giuseppe

Mancia – Ex officio; Francisco Morales-Olivas; Wolfgang Rascher; Josep Redon; Franz Schaefer; Tomas Seeman; George

Stergiou; Elke Wühl; Alberto Zanchetti

Hypertension in Children and Adolescents: Recommendations of the ESH

1. Introduction and purpose

2. Definition and classification

3. Diagnostic evaluation

4. Preventive measures

5. Evidence for therapeutic management

6. Therapeutic strategies

7. Therapeutic approaches under special conditions

8. Treatment of associated risk factors

9. Screening of secondary forms

10. Long-term follow-up

11. Future research

12. Implementation of guidelines

13. Bibliography

Figures

Tables

Boxes

Introduction and Purpose (I)

There is growing evidence that children and adolescents with mild BP elevation are much more common than was thought in the past

Longitudinal studies have demonstrated that BP abnormalities in those age ranges do not infrequently translate into adult hypertension

Hypertension in children and adolescents has gained ground in CV medicine thanks to the progress made in several areas of pathophysiological and clinical research

Introduction and Purpose

Introduction and Purpose (II)

The remoteness of cardiovascular events from the BP values of many years before makes the relationship between those BP values and the events difficult to establish

Large intervention studies are lacking, and therefore cannot provide hints about cutoffs for evidence-based recommendations

Many of the classifications and recommendations in children are based on statistical considerations and are the result of assumptions or extrapolations from evidence obtained in adults

Introduction and Purpose

Characteristics of blood pressure

Blood pressure increases during growth and maturation

Adolescence is a fast growth period during which body mass and BP change rapidly

Reference BP values over the last few decades have been referred to as ones specific for sex, age and/or height

Introduction and Purpose

Definition and classification

SBP and/or DBP Percentile

Normal <90th

High-normal ● ≥ 90th to <95th ● ≥ 120/80 even if below 90th percentile in adolescents

Stage 1 hypertension 95th percentile to the 99th percentile plus 5 mmHg

Stage 2 hypertension >99th percentile plus 5 mmHg

Definition and classification

Repeatedmeasurements

≥P95th<P90th

NORMOTENSION

<P90th >P90th

SBP and/or DBP

HYPERTENSION

Evaluation foretiology and

organ damage

P90-95th

FOLLOW-UP

NORMOTENSION

Repeatedmeasurements

Diagnostic algorithm of hypertension

Figure 1

Definition and classification

Blood pressure measurement

The recommended method is auscultatory

Use K1 for systolic BP and K5 for diastolic BP

If the oscillometric method is used, the monitor needs to be validated for this age group

If hypertension is detected by the oscillometric method, it needs to be confirmed using the auscultatory method

Use the appropriate cuff size according to arm width

Children above 3 years of age who are seen in a medical setting should have their BP measured

In younger children, BP should be measured under special

circumstances that increase the risk for hypertension

Diagnostic evaluation

Box 1

Indications for 24-hour ABPM

● During the process of diagnosis

– Confirm hypertension before starting antihypertensive drug treatment

– Type 1 diabetes

– Chronic kidney disease

– Renal, liver or heart transplant

● During antihypertensive drug treatment

– Evaluation of refractory hypertension

– Assessment of BP control in children with organ damage

– Symptoms of hypotension

● Clinical trials

● Other clinical conditions

– Autonomic dysfunction

– Suspicion of catecholamine-secreting tumoursBox 2

Diagnostic evaluation

● Organ damage is common and LV hypertrophy is the most prominent type

● Echocardiography should be performed. Left Ventricular Hypertrophy is an indication to initiate or intensify antihypertensive therapy

● Microalbuminuria is recommended for routine clinical use

● Carotid intima-media thickness, arterial stiffness, retinal and CNS assessment are not recommended for routine clinical use

Evaluation of organ damage

Diagnostic evaluation

Evaluation for Secondary Hypertension

● Very young children with Stage 1 or Stage 2 hypertension

● Children or adolescents with Stage 2 hypertension

< 1 month< 1 monthRenal arterial thrombosisRenal arterial thrombosis

Congenital renal diseaseCongenital renal disease

Umbilical canalizationUmbilical canalization

Bronchopulmonary dysplasiaBronchopulmonary dysplasia

>1 month to <6 years>1 month to <6 yearsRenal parenchymal diseaseRenal parenchymal disease

Coarctation of the aortaCoarctation of the aortaRenovascular diseaseRenovascular disease

> 6 years to 10 years> 6 years to 10 yearsRenal parenchymal diseaseRenal parenchymal disease

Renovascular diseaseRenovascular disease

Essential hypertensionEssential hypertension

> 10 years> 10 years Essential Hypertension Essential Hypertension

Renal Parenchymal DiseaseRenal Parenchymal DiseaseExogenous Hypertension (drugs)Exogenous Hypertension (drugs)

Endocrine DisordersEndocrine DisordersCoarctation of the aortaCoarctation of the aorta

Mendelian Genetic DisordersMendelian Genetic Disorders

Age-distribution of hypertension etiologies

Screening for secondary forms

Life style recommendations to reduce high BP values

Box 6

Preventive measures

GOAL GOAL

● Maintain or achieve BMI <85Maintain or achieve BMI <85thth

GENERAL RECOMMENDATIONSGENERAL RECOMMENDATIONS

● Moderate to vigorous physical aerobic activityModerate to vigorous physical aerobic activity 40 minutes, 3-5 days/week and 40 minutes, 3-5 days/week and avoid more than 2 hours daily of sedentary activitiesavoid more than 2 hours daily of sedentary activities

● Avoid intake of excess sugar, excess soft drinks, saturated fat and salt and Avoid intake of excess sugar, excess soft drinks, saturated fat and salt and recommend fruits, vegetables and grain productsrecommend fruits, vegetables and grain products

● Implement the Implement the behavioural changesbehavioural changes (physical activity and diet) tailored to (physical activity and diet) tailored to individual and family characteristicsindividual and family characteristics

● Involve the parents/family as partnersInvolve the parents/family as partners in the behavioural change process in the behavioural change process

● Provide Provide educational supporteducational support and materials and materials

● Establish Establish realistic goalsrealistic goals

● Develop a Develop a health-promoting reward systemhealth-promoting reward system

● Competitive Competitive sports participation should be limited onlysports participation should be limited only in the presence of in the presence of uncontrolled stage 2 hypertensionuncontrolled stage 2 hypertension

When to initiate antihypertensive treatment

Figure 3

Evidence for therapeutic management

High-normal BPHigh-normal BP HypertensionHypertension Life threatening Life threatening hypertensionhypertension

One or more of the following conditions:One or more of the following conditions:SymptomaticSymptomaticSecondarySecondary

Organ damageOrgan damageDiabetesDiabetes

NONO YESYES

NonpharmacologicalNonpharmacologicaltreatmenttreatment

PharmacologicalPharmacologicaltreatmenttreatment

Blood pressure targets

In generalIn general

● BP <90th age, sex and height specific percentileBP <90th age, sex and height specific percentile

Chronic kidney diseaseChronic kidney disease

● BP <75th percentile in children without proteinuria BP <75th percentile in children without proteinuria and <50th percentile in cases of proteinuriaand <50th percentile in cases of proteinuria

● 24-hour ABP24-hour ABP strongly recommended. strongly recommended.

● Goals: <75th percentile in children without proteinuria and Goals: <75th percentile in children without proteinuria and <50th percentile in cases of proteinuria<50th percentile in cases of proteinuria

Evidence for therapeutic management

How to initiate antihypertensive treatment

Therapeutic strategies

MonotherapyMonotherapy(low dose(low dose

4-8 w)4-8 w)

MonotherapyMonotherapy(full dose)(full dose)

CombinationCombinationtherapytherapy

Switch Switch drugdrug

No response

No response

No response

Particular conditionsParticular conditionsStage 2Stage 2

Chronic kidney diseaseChronic kidney diseaseSecondarySecondary

All hypertensivesAll hypertensives

Side effects

Class Efficacy studies

Diuretics Clorthalidone, HCZT

-blockers Atenolol, Metoprolol, Propanolol

CCB Amlodipine, Felodipne, Isradipine

ACEi Captopril, Enalapril, Fosinopril, Lisinopril, Quinapril, Ramipril

ARB Candesartan, Irbesartan, Losartan, Valsartan

Antihypertensive agents with efficacy and safety studies in children and adolescents

Therapeutic strategies

● Initial frequentInitial frequent follow up visits to monitor follow up visits to monitor BPBP control, organ damagecontrol, organ damage Side effects of treatmentSide effects of treatment Other rOther reversible risk factorseversible risk factors

● Once BP stable and in target rangeOnce BP stable and in target range, , frequency of visits can be frequency of visits can be reducedreduced

● HomeHome monitoring of BP or 24 hour monitoring of BP or 24 hour ABPMABPM can facilitate follow up can facilitate follow up aassessmentsssessments

● Dependent on the Dependent on the underlying causeunderlying cause of hypertension of hypertension, further , further investigative procedures may be indicated to monitor success of investigative procedures may be indicated to monitor success of surgical intervention or medical treatmentsurgical intervention or medical treatment

Long-term follow-up

Long-term follow-up

Future research

Develop accurate non-mercury sphygmomanometer for auscultatory Develop accurate non-mercury sphygmomanometer for auscultatory BP measurement and oscillometric BPBP measurement and oscillometric BP

Reference values for office, home and ambulatory BP based on a Reference values for office, home and ambulatory BP based on a European pediatric populationEuropean pediatric population

Increase knowledge in the use of out-of-office BP measurementsIncrease knowledge in the use of out-of-office BP measurements

Collect information about early organ damage to refine risk Collect information about early organ damage to refine risk stratification and use the information to set intermediate objectives stratification and use the information to set intermediate objectives during treatmentduring treatment

Box 10

Future research

Future research

Conduct controlled studies with antihypertensive drugs in order to Conduct controlled studies with antihypertensive drugs in order to improve knowledge about specific benefits and disadvantages of BP improve knowledge about specific benefits and disadvantages of BP lowering agents and establish adequate doses lowering agents and establish adequate doses

Conduct large, long term randomized therapeutic trials using onset of Conduct large, long term randomized therapeutic trials using onset of organ damage to obtain information about when to initiate organ damage to obtain information about when to initiate antihypertensive drug treatment and about BP goals antihypertensive drug treatment and about BP goals

Box 10

Future research

Implementation of Guidelines

Joint efforts should be started so as to promptly implement the Joint efforts should be started so as to promptly implement the guidelinesguidelines

Synergistic actions at various levels (learned societies, expert Synergistic actions at various levels (learned societies, expert committees, GPs, pediatricians, nurses and other healthcare committees, GPs, pediatricians, nurses and other healthcare providers, school, parents and policy makers) should be providers, school, parents and policy makers) should be encouraged to participateencouraged to participate

The role of learned Societies, particularly ESH, is crucial for The role of learned Societies, particularly ESH, is crucial for spreading the guidelines and the acceptance by National spreading the guidelines and the acceptance by National Hypertension Societies and LeaguesHypertension Societies and Leagues

Active support of research is necessary in order to gain knowledge Active support of research is necessary in order to gain knowledge helpful to future developments in the field, so studies that are helpful to future developments in the field, so studies that are recommended should be promptly initiatedrecommended should be promptly initiated

Implementation guidelines

Hypertension in Children and Adolescents: Recommendations of the European Society of Hypertension

Renata Cifkova, Prague

J Kennedy Cruickshank, Manchester

Michael J Dillon, London

Isabel Ferreira, Maastricht

Cecilia Invitti, Milan

Tatiana Kuznetsova, Leuven

Stephane Laurent, Paris - Ex officio

Empar Lurbe, Valencia – Chair

Giuseppe Mancia, Milan - Ex officio

Francisco Morales-Olivas, Valencia

Wolfgang Rascher, Erlangen

Josep Redon, Valencia

Franz Schaefer, Heidelberg

Tomas Seeman, Prague

George Stergiou, Athens

Elke Wühl, Heidelberg

Alberto Zanchetti, Milan