Hypertension

Question 1

Give the normal BP in children

Answer 1

Normal BP - <90th percentile systolic and diastolic BP for age and
gender

Pre-hypertension – BP 90th to 95th percentile OR >120/80 mmHg

Hypertension – systolic or diastolic BP >95th percentile for age and gender confirmed on 3 separate accounts with an appropriately
sized cuff and technique OR elevated BP in a symptomatic child in a single determination

Question 2

Appropriate BP cuff:

Answer 2

Appropriate BP cuff:
o Cuff bladder length = 80-100% of arm
circumference
o Cuff bladder width = 40% of arm
circumference

Question 3

Normal BP

Answer 3

1 to <13 years old:
<90th percentile

> 13 years old:
<120/80

Question 4

What is considered as elevated BP or Prehypertension

Answer 4

1 to <13 years old:
≥90th to >95th percentile OR
120/80 to <95th percentile (whichever is lower)

> 13 years old:
120/80 to 129/80 mmHg

Question 5

Stage 1 Hypertension

Answer 5

1 to <13 years old:
≥95th percentile to <95th percentile + 12 mmHg OR
130/80 to 139/89 (whichever is lower)

> 13 years old:
130/80 to 139/89 mmHg

Question 6

Stage 2 hypertension

Answer 6

1 to <13 years old:
≥95th percentile + 12 mmHg OR
≥140/90 to 139/89 (whichever is lower)

> 13 years old:
≥140/90

Question 7

BP cut off per age grp

Answer 7

> 95th cut off:

NB ≥95
8-30d ≥105
1mo-2yo ≥115/75
2-5 yo ≥130/80
6-11 yo ≥135/85
>12 yo ≥140/90

Question 8

What is white coat hypertension?

Answer 8

White coat HTN – BP ≥95th percentile in the clinical setting but <95th percentile outside.
- Diagnosed by ABPM when the SBP and DBP are <95th percentile and SBP and DBP load (% readings >95th percentile of SBP or DBP) are <25%

Question 9

What is masked hypertension?

Answer 9

Masked HTN – px has N office BP but elevated BP on ABPM.
- Significant risk for end organ hypertensive damage
- Risk factors: obesity, secondary HTN (CKD, repaired
CoA)

Question 10

Study HYPERTENSION STAGES CARD

Question 11

What is the epidemiology of hypertension?

Answer 11

Epid
- Essential HTN is more common in adolescence (>50% in obese)
- (+) role of genetics – 65% if both parents HTN, 28% if 1, 3% if none
- Incidence rate 0.6-11%

Question 12

Etiology of hypertension

Answer 12

Etiology
- BP = CO x PVR
- RF: SGA, FTT, bruits, unexplained sz, headache, dizziness, epistaxis, anorexia, CHF

Question 13

What are the types of hypertension?

Answer 13

2 Types of HTN
1. Essential/Primary HTN (10%) – specific etiology unknown
- >6yo, (+)FHx, obesity/overweight
2. Secondary HTN (90%) – usually <6yo. Known underlying cause
>90% caused by 3 conditions:
a. Renal parenchymal disease
b. Renal artery disease
c. Coarctation of the aorta
Systolic HTN predictive of primary HTN
Diastolic HTN predictive of secondary cause
Neonatal HTN – MAP >70mmHg. Usually transient, sec. to RDS, BPD, renal artery thrombosis (sec to UVC/UAC)

Question 14

Common Causes of secondary HTN:

Answer 14

1. Renal (90%) – parenchymal/renovascular
2. CV – CoA (MC), conditions with large SV (PDA, AI, systemic AV fistula – systolic HTN)
3. Endocrine – Adrenal dysfunction, hyperthyroidism (systolic), pheochromocytoma, hyperaldosteronism,
   Cushing’s
4. Neurogenic – inc ICP, dysautonomia
5. Drugs – CS, amphetamines, antihistamine, cocaine
6. Miscellaneous – hyperNa, hypervolemia

Question 15

Clinical manifestations of hypertension

Answer 15

CM
1. Asymptomatic
2. Sx of underlying disease
3. Headache/nape pain
4. BOV
5. Dizziness
6. Chest pain

Question 16

Diagnostics for hypertension

Answer 16

1. Adequate Hx and PE
2. Accurate BP measurement of UE and LE (palpate brachial and femoral pulses): oscillatory and auscultatory BP
   - Should be checked annually >3yo
   - Checked at every clinic visit if with obesity, taking meds that can inc BP, renal ds, with aortic arch obstruction, CoA, DM

Question 17

Study algorithm

Question 18

What is ABPM?

Answer 18

Ambulatory BP Monitoring (ABPM) – px wears a BP cuff continually x 24h, with readings q20-30min. Allows evaluation of out-of-office and circadian BP patterns
- Indications:
o Confirmation of the dx of HTN for children
with elevated office BP for >1yr or with BP
values at stage 1 HTN after 3 visits
o Differentiation between ambulatory
(sustained HTN) vs white coat HTN
o High risk conditions: secondary HTN, CKD or
structural renal abnormalities, DM, solidorgan
transplant, obesity, OSAS, repaired
CoA, genetic syndromes (NF, Turner,
Williams, CoA), treated hypertensive pxs,
preterm, research

Home BP measurement – commonly for tx monitoring
3. ECG – high sp but poor sn for LVH, not recommended
for screening LVH
4. Fundoscopy
5. 2D echo – assess cardiac damage (LV mass, geometry,
function) at the time of consideration of pharma Tx for
HTN

Question 19

Management

Answer 19

The goal of Tx is to keep BP <90th percentile for age and sex or <130/80 mmHg in adolescents
1. 1st line: non-pharmacologic – weight control, DASH diet (low fat, low salt), moderate to vigorous exercise
(isotonic, dynamic) x 30-60min 3-5x/week, avoid HTN inducing substances (alcohol, smoking, drugs)
- 5-2-1-0-0: 5 servings of fruits and vegetables/d, <2 hrs
of TV/computer per d, 1 hr exercise/d, 0 sugared beverages, 0 smoking
2. Pharmacologic – reserved for sustained, sx’c, acute, severe HTN, (+) evidence of target-organ damage, failure of nonpharma tx
- Indications: failed >6 mos of lifestyle change, sx’c HTN, stage 2 HTN without clearly modifiable risk factors (obesity)
- Stepwise approach

Question 20

What is the Stepwise approach?

Answer 20

Step 1: Initial drug started on the lowest recommended dose.
Dose increased until the desired BP goal achieved.

1. Thiazide-type diuretic – for DM, BA
   - HCTZ 1 mkd (max 3mkd-50mg/d): DOC
   - Chlorthalidone 0.3 mkd (max 2mkd-50mg/d)
2. B-adrenergic inhibitor – with hyperkinetic HTN, migraine headache
   - Atenolol 1-2 mkd (max 2mkd-100mg/d)
   - Metoprolol 1-5 mkd (max 2mkd-100mg/d)
   - Propanolol 2-4 mkd BID-QID (max 4mkd-640mg/d)
3. ACEI – if with DM and renal ds
   - Captopril <6mos 0.1-1mkd BID-TID; >6mos 1-5mkd BID-TID (max 6mkd)
   - Enalapril 0.1-0.4mkd OD-BID (max 0.6mkd or 40mg/d)
   - Iosinopril, Lisinopril
4. ARBs – with DM and renal ds
   - Losartan 0.7mkd (max 1.4 mkd to 100mg/d)
   - Irbesartan
5. Calcium channel blocker (CCB) – with migraine headache
   - Nifedipine 0.6-0.9 mkd (20-40mg) TID-QID (max 3mkd to 120mg/d)
   - Amlodipine 6-13yo: 5-10mg OD
   - Felodipine 2-5mg/d (max 10mg/d)
   - Verapamil 80-160mg TID
   Step 2: once highest recommended dose is reached, a drug from a different class should be added.
   - Drugs with complementary MOA
   a. Diuretics + ACEI
   b. Diuretic/B-blocker + vasodilator
   o Vasodilator = Hydralazine 0.15-0.2mkdose
   q4-6h or 0.5mkd (max 7.5mkd to 200mg/d)

Step 2: once highest recommended dose is reached, a drug from a
different class should be added.
- Drugs with complementary MOA
a. Diuretics + ACEI
b. Diuretic/B-blocker + vasodilator
o Vasodilator = Hydralazine 0.15-0.2mkdose
q4-6h or 0.5mkd (max 7.5mkd to 200mg/d)
Step 3: Add a 3rd drug if still uncontrolled
Optimum tx: least amount of meds to maintain BP goal with high
degree of compliance
Step down: when BP controlled, gradual withdrawal of drug
Hypertensive emergency/crisis – HTN + signs of hypertensive encephalopathy + sz
- Treated with IV HTN meds to decrease BP by <25% over 1st 8 hrs –> gradually to N BP over the next 26-48h
o To prevent cerebral hypoperfusion
Hypertensive urgency – HTN + severe headache, vomiting
- IV/po HTN meds depending on sx

Question 21

Medications (Rx)

Answer 21

Rx:
1. Nicardipine 1-3 ug/kg/min IV (onset 10-20min)
2. Sodium nitroprusside 1-8 ug/kg/min (30s)
3. Hydralazine 0.15-0.5mkdose (max 20mg/dose) (onset
10-30min)
4. Esmolol 100-500 ug/kg/min (immediate)
5. Labetalol 0.2-1 mkdose (upto 40mg/dose) (5min)

Question 22

Prognosis and follow up

Answer 22

Prognosis
- 65% curability HTN in children. Good.
Follow-up
- Tracking: f/u child with HTN into adolescence and
adulthood; endorse to adult cardio due to inc chance
of developing HTN.
- Patients treated with antiHTN drugs should f/u q4-6
wks for dose adjustments until goal BP reached; then
q3-4.
- Patients with lifestyle change only should f/u q3-6 mos

Question 23

Differentials for elevated BP

Answer 23

DDx: Neuroblastoma (p.192)

PSGN?