Download Hypertension - PCA Pediatric Cardiology

Hypertension in Pediatrics
Dominic Blurton M.D.
Pediatric Cardiologist
Pacific Cardiovascular Associates
Children with hypertension become adults
with hypertension
Hypertension
Why does it matter?
 Several studies evaluated autopsy findings
and coronary risks in children and young
adults.
 Found that hypertension was a strong
predictor of fatty streaks and fibrous
plaques in the coronaries.
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Risk factors of early coronary disease
Family history (age of disease <55)
 Cigarette smoking
 Hypertension
 Diabetes
 Hyperlipidemia (and low HDL)
 Physical inactivity
 Obesity
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Who needs blood pressure measured
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Current recommendations state that children
over 3 years of age should have their BP
checked during every health care
encounter.
Conditions for which BP should be monitored in
children < 3 years of age
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History of prematurity, very low birth weight
Congenital/acquired heart disease
Recurrent urinary tract infections, hematuria, proteinuria
Known renal disease or urologic malformations
Family h/o congenital renal disease
Solid organ transplant
Malignancy
Treatment with drugs known to raise blood pressure
Systemic illnesses associated with hypertension
Evidence of elevated intracranial pressure
Technique
Technique - Automated machines
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frequently used for BP measurement
ease of use
minimization of bias on the part of the health care
worker.
greater success in obtaining a BP in newborns and
infants.
Technique - Automated machines
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only measure systolic and mean BP and subsequently
calculate the diastolic BP leading to inaccuracies of the
diastolic value.
The gold standard for BP measurement is auscultation and
use of the first and fifth Korotkoff sounds
Technique
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In practice, the automated machine is likely
sufficient as a primary screening tool but for
borderline or high readings, corroboration
using manual auscultation should be
performed.
Technique
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patient should be sitting at rest for five minutes prior to
measurement and the right arm should be relaxed and
supported with the cubital fossa at the level of the heart.
Choosing the proper cuff size for measuring BP is critical
for reliable measurements.
The major components of the apparatus are:
 The bladder which is the expandable rubber rectangle
which is connected to an inflation/deflation bulb and to
a manometer which reflects the pressure within the
bladder
 The cuff which encases the bladder and wraps
completely around the limb
Technique - Fit
Ideal Blood Pressure Cuff
Bladder length
Bladder width
(1/2 of length)
Maximum allowable arm circumference so that bladder length is at
least 80% of arm circumference
Technique – Fit of Bladder
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wide variation in BP cuff dimensions but ideally the width
of the bladder should be half the length of the bladder.
In relation to the arm, the width of the bladder should be
about 40% of the midpoint arm circumference
the length of the bladder should encircle at least 80% of
the arm. (The bladder can encircle 100% of the arm and even overlap
without affecting the quality of the measurement in children)
Bladder length
Bladder width
(1/2 of length)
Summary of fit
Bladder width = 40% of circumference
 Cuff width = 66-75% of upper arm length
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Technique - Sounds
Phase I: First appearance of clear, repetitive, tapping
sounds. This coincides approximately with the reappearance
of a palpable pulse. (BP by palpation)
 Phase II: Sounds are softer and longer, with the quality
of an intermittent murmur.
 Phase III: Sounds again become crisper and louder.
 Phase IV: Sounds are muffled, less distinct, and softer.
 Phase V: Sounds disappear completely.
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Technique - Sounds
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In cases of young children, pregnant women, or high
output states, the last audible Korotkoff sound may
approach zero and in this case, the fourth (muffled, less
distinct) Korotkoff sound may be used as the diastolic
pressure.
Web search: NIH blood pressure charts
Definition
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systolic or diastolic blood pressure that is greater than the
95th percentile for sex, age and height on at least 3
separate occasions.
Prehypertension is defined as levels between the 90th and
95th percentiles.
Typically children and adolescents are considered
prehypertensive with a BP greater than 120/80.
Definition
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Normal - < 90th%
Prehypertension – 90th-95th% (or if BP > 120/80)
Stage I hypertension – 95-99th%
Stage II hypertension - >99th%
Symptoms
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Asymptomatic
Headache
Dizziness
Nausea
Vomiting
Personality changes
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Epistaxis
Abdominal pain
Blurry vision
CHF
Stroke
Irritability
Past and current history
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Umbilical catheters
BPD
Coarctation surgery
Cardiac symptoms
Renal hx (infection, trauma, surgery)
Weakness, muscle cramp
Medications (steroid, beta agonist, OTC)
Smoking
Family History
Hypertension
 Early heart disease or stroke <55 years
 Familial renal disease
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Physical Exam
Growth
 Pulses (differential, radial-femoral delay)
 Abdominal bruits
 Renal tenderness
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The initial evaluation for Stage I hypertension
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basic metabolic panel, urinalysis, complete blood
count, and renal ultrasound.
Additional workup with comorbid conditions
including diabetes mellitus and renal disease
End Organ damage: All hypertensive patients
should have an echocardiogram at diagnosis and at
regular intervals thereafter to assess left
ventricular hypertrophy/mass.
Evaluation
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Prehypertensive patients should be rechecked in 6
months and should have weight management
counseling if overweight.
Stage I patients should be rechecked every few
weeks and if the BP remains elevated, referral for
secondary evaluation should be made.
Stage II patients require more urgent evaluation
with likely early initiation of therapy.
Etiology
Primary (Essential)
 Secondary
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Incidence of primary is unknown.
 Over 90% of secondary is due to
 Renal disease (parenchymal or arterial)
 Coarctation of the aorta
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Essential (Primary) hypertension
Adolescents
 Mild hypertension
 Overweight/strong family history
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Secondary hypertension
Pre-pubertal patients
 Severe hypertension
 Diastolic/nocturnal hypertension (Night
time blood pressure normally drops 1015%.)
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In general, the younger and more severe, the
more likely you will identify an underlying
cause.
HISTORY AND PHYSICAL
EXAM
CAUSE
WORKUP
Family history of hypertension,
mild hypertension, obesity
Primary hypertension
Evaluate for comorbidities:
fasting lipid panel/glucose
History of drug use, acne,
hirsutism
Steroids/drug use
Drug screen
Urinary tract infections,
Primary renal disease
pyelonephritis, congenital kidney (chronic pyelonephrits,
abnormalities, palpable kidney
renal scar, polycystic
disease)
Umbilical arterial catheter as
neonate, abdominal bruit
Renovascular disease
Decreased lower extremity
Coarctation of the aorta
pulses, drop in BP from upper to
lower extremities
Metabolic panel, CBC, renal
ultrasound
Doppler flow study, MRA, CT
scan, arteriography
Echocardiogram
HISTORY AND PHYSICAL
EXAM
CAUSE
WORKUP
Tachycardia, flushing, weight
loss, abdominal mass
Hyperthyroidism,
pheochromocytoma,
neuroblastoma
Plasma and urine
catecholamines, endocrine
workup
Hyponatremia, muscle
weakness
Hyperaldosteronism
Plasma renin evaluation
Sleep history, snoring, tonsillar
hypertrophy
Obstructive sleep
apnea
ENT evaluation,
polysomnography
Moon facies, truncal obesity
Cushing syndrome
Endocrine evaluation
Dysmorphic features such as
elfin facies, webbed neck, wide
spaced nipples
Genetic syndromes:
Williams/Turners
Genetic evaluation,
chromosomal evaluation
Arthralgia/arthritis, rash
SLE, collagen vascular
disease
Rheumatologic evaluation
No other family history or risk
factors
White coat
hypertension
Ambulatory blood pressure
monitoring
Management
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Non-pharmacologic – lifestyle changes
 Weight loss (BMI)
 Exercise
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Avoid smoking
 Avoid OCP (estrogen)
Avoid competitive sports and isometrics if >99%
or end organ damage
Low salt diet not shown to work in adolescents
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Treatment in Children
ACE inhibitor
 Calcium channel blocker
 Beta Blocker
 Angiotensin Receptor Blockers
 Alpha Blockers
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Pediatric Obesity
Body mass Index
Normal weight = 18.5-24.9
 Overweight = 25-29.9
 Obesity = BMI of 30 or greater
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Internet Search: NHLBI BSA calculator
Diet
Exercise
Ethnicty
Economics
Marketing Influences