Download Hypertension-nowa-wersja

Hypertension
Karolina Narębska
Oddział Kliniczny Pediatrii i Nefrologii
Wojewódzki Szpital Specjalistyczny dla Dzieci i
Dorosłych w Toruniu
Hypertension - general
informations
- One of the most common disease in population
~30% of adult people.
- In children ~ 1-3% young population and mainly
it has secondary character ( secondary
hypertension ).
- Main causes of hypertension in pediatrics are
acquired and congenital renal diseases.
The younger hypertensive child is, the bigger
likelihood of secondary hypertension is!!!
Hypertension- general information
continued
- Primary hypertension refers to older
children ( over 10yrs) and it is strongly
connected with obesity and lifestyles risk
factors.
It has unknown origin ( genetic and
environmental factors )
There are also known 9 types of monogenic
hypertension, like e.g. Liddle’a syndrome,
Gordon syndrome, etc.
Hypertension - etiopathogenesis
Blood pressure depends on CO and TPR
according to the following formula:
RR = CO ( cardiac output) x TPR ( total
peripheral resistance )
CO depends on the left ventricular
contractility and volemia.
TPR depends on contraction vessels factors
and the main is RAAS ( renineangiotensine-aldosterone system ).
Angiotensinogen
RAAS
RENINE
Angiotensin I
Angiotensinase
ANGIOTENSIN II
Angiotensin receptors
Vessels contraction Symphaticotony
Angiotensin III
Aldosterone release
Na+ retention Fluid retension
Increase of the TPR
Increase of the fluid
volume
Increase of the blood pressure
Hypertension - definition
Hypertension is defined as average
systolic and/or diastolic blood pressure
greater than the 95th percentile for:
- gender
- age
- hight percentile
measured on at least 3 separate
occasions.
Normal blood pressure
Normal blood pressure is defined as
systolic and/or diastolic blood pressure
lower than the 90th percentile for age,
gender, height percentile.
Prehypertension
Prehypertension is defined as systolic and/or
diastolic blood pressure between the 90th and
95th percentile for age, gender and height
percentile,
but also
as in adults, children and adolescents whose
blood pressure is greater than 120mmHg (
systolic ) and/or 80mmHg ( diastolic ) are also
classified as prehypertensive
„White-coat” hypertension
White-coat hypertension refers to the
patients, whose blood pressure is greater
than the 95th percentile in the
physicians office, but less than the 90th
percentile outside a clinical setting.
Stages of hypertension
•
•
•
•
•
Stage 1 hypertension
Stage 2 hypertension
Severe hypertension
Hypertensive urgency
Hypertensive emergency
Stage 1 hypertension
is defined as blood pressure levels ranging
from the 95th to 5mmHg above the 99th
percentile.
Asymptomatic patients with stage 1
hypertension may undergo a diagnostic
evaluation before initiation of treatment
Stage 2 hypertension
is defined as blood pressure levels greater than
5mmHg above the 99th percentile.
Patients with stage2 hypertension should
undergo more timely evaluation and initiation of
hypotensive therapy.
Symptomatic patients with stage 2
hypertension require immediate
pharmacologic treatment and consultation with
an expert.
Severe hypertension
is defined as blood pressure levels
greater than 30mmHg above the 99th
percentile for age, gender and hight
percentile.
Hypertension urgency
Impending organ failure during
hypertension, usually with unspecific
symptoms like headaches and vomiting.
Hypertension emergency
• Done or ongoing organ damage during
hypertension, most often leading to organ
failures, with the symptoms of
encephalopathy.
• Those hypertension emergency stages
require immediate intervention.
Hypertension - measurement
• The rules of blood pressure ( BP ) measurement:
- Child shouldn’t eat or drink for at least 30min before
measurement
- Child should rest in a sitting position for at least 5
minutes with feet on the floor and arm supported on the
heart level
- The cuff bladder should cover 80% to 100% of the arm
circumference and two thirds of length of the upper arm
- Remember: smaller cuff sizes result in an increase of
blood pressure and bigger cuff sizes result in a
decrease of blood pressure!!!
- The cuff should be inflated to a pressure 20 to 30mmHg
higher than the patient’s systolic blood pressure and then
deflated at 2 to 3mmHg each second
- Measurement should be done on the right arm
Measurement - continued
Systolic pressure - occurs when the first
sound is heard during cuff deflation ( the
first Korotkoff sound )
Diastolic pressure - occurs at the point
before disappearance of sounds ( the
second Korotkoff sound )
Measurement - continued
• During the first examination the blood
pressure should be measured on four limbs
• In babies and infants untill they reach vertical
position the blood pressure levels on lower limbs
are lower than on upper limbs
• In babies while they are sleeping the systolic
blood pressure levels are lower by 5-7mmHg.
• In a 2-year-old child, who can stand vertically,
the blood pressure levels on lower limbs become
about 20mmHg greater than on upper limbs; in
adolescents about 30-40mmHg greater.
Measurement - continued
• Next measures should be taken on the
abducted right arm laying on the level of
the heart.
• Every measurement should be repeated
2 or 3 times per an examination.
• The difference of measurement between
two arms greater than 5mmHg must be
notified in patient’s card.
When to start to measure blood
pressure ( BP)?
• In children aged of three or more the BP should be
measured at least once a year and during routine
examination
• In children under the age of three the BP should be
measured in the following situations:
- When a perinatal history is affected: prematurity, LBW,
intensive therapy during perinatal period
- Congenital anomalies
- Recurrent urinary tract infections, chronic kidney disease
- Tumors
- When drugs effecting BP are used
- Diseases connected with hypertension ( neurofibromatosis,
hyperthyroidism )
ABPM - ambulatory blood pressure
monitoring
ABPM method assesses:
- 24-hour blood pressure measurement
- variability of 24-hour blood pressure
referring to different periods of day and
night, during some activities
ABPM results have the meaning in diagnosis,
prognosis and monitoring of the treatment.
The norms of ABPM are published for
children from 120cm height.
ABPM - assessment
• MSBP - stands for mean ( 24-hour ) systolic blood
pressure
• MDBP - stands for mean ( 24-hour ) diastolic blood
pressure
• Loads of BP ( percent of blood pressure levels
greater than the 95th percentile ) during the day
and night ( norm less than 20% ).
• Dipping of BP in the night (norm is minimum 10%)
• The lack of night dipping of BP is an extra risk
factor of cardiovascular incidents, especially in
patients with diabetes.
ABPM – indications
Suspicion of the „white coat” hypertension
Organ changes in patients with prehypertension
Paroxysmal hypertension
Resistance to drugs hypertension
Assessment of night blood pressure or suspicion
of high blood pressure in the night
- Assessment of effectiveness hypotensive
treatment in patients with too big reduction of
blood pressure
- Assessment of indications for hypotensive
treatment
-
Hypertension in ABPM
• Mean 24-hour systolic and/or diastolic
blood pressure greater than the 95th
percentile for age, gender and height.
( We use special ABMP percentile charts )
MAP – mean arterial pressure
MAP is defined as hypothetic mean blood
pressure during one cycle of the heart
MAP= DP+1/3 ( SP-DP )
Norma: 75-100mmHg
A normal MAP has clinical meaning in
supporting organ perfusion ( good blood
flowing ).
MAP under 60mmHg results bed perfusion
and hypoxia.
Causes of secondary hypertension
whatever the age
1. Hypertension in kidney diseases:
- renal parenchymal diseases secondary to
reflux nephropathy, obstructive uropathy,
chronic renal infections ( pyelonephritis! )
- primary and secondary glomerulonephritis,
- polycystic kidney diseases,
- Wilm’s tumour
- chronic kidney diseases
2. Renovascular hypertension – eg. bilateral
renal artery stenosis ( often with CoA )
Causes of secondary hypertension
whatever the age
3. Endocrine-origin hypertension:
- pheochromocytoma
- primary hyperaldosteronism ( Conn
syndrome ) – hypernatremia with hypokaliemia
- Cushing syndrome
- Congenital adrenal cortex steroidogenesis
abnormalities ( like eg congenital adrenal cortex
hypertrophy )
- hyperthyroidism, hypothyroidism
- Hyperparathyroidism ( with high calcium serum
level, PTH and vitD3 )
Causes of secondary hypertension
whatever the age
4. Others:
- coarctation of the aorta
- Turner syndrome
- obstructive sleep apnea ( OSA )
- multiple neuritis
- neurofibromatosis ( NF )
- drug-induced hypertension
- and many more…
Most common causes of
hypertension by age
Newborns:
- renal artery or venous thrombosis
- renal artery stenosis
- congenital renal abnormalities (e.g.
congenital renal dysplasia )
- coarctation of the aorta
- bronchopulmonary dysplasia
Most common causes of
hypertension by age
First year:
- coarctation of the aorta
- renovascular diseases
- renal parenchymal disease
- iatrogenic ( medication, volume overload )
- tumour
Most common causes of
hypertension by age
Infancy to 6year:
- renal parenchymal diseases secondary to
reflux nephropathy, obstructive uropathy,
chronic renal infections ( pyelonephritis! )
and nephrotic syndrome,HUS,
glomerulonephritis, polycystic kidney disease
- renovascular disease ( stenosis of renal artery )
- coarctation of the aorta
- endocrine causes ( hyperthyroidism,
hypercalcemia, mineralocorticoids excess)
- iatrogenic
Most common causes of
hypertension by age
6-10yrs:
- renovascular diseases ( stenosis of
renal artery )
- essential/idiopathic/primary hypertension
- renal parenchymal disease
- thyroid diseases
- pheochromocytoma
- neurofibromatosis
Most common causes of
hypertension by age
Over 10yrs:
- primary hypertension!!!
- renal parenchymal diseases
- and others
Diagnostic evaluation
1. Finding the cause of hypertension (
medical history )
2. Assessment of organ changes and risk
factors ( medical history and physical
examination )
Medical history
- family history of hypertension ( primary
hypertension )
- lifestyle factors ( diet, sport, salt intake )
- cardiovascular risk factors ( in patients and in their
families like eg. premature atherosclerosis,
cardiovascular disease )
- concomitant diseases that could affect prognosis
and guide treatment ( especially diabetes )
- medications
- renal diseases ( in patients and their families )
- substance abuse
Physical examination
1. Inspection:
- skin: cafe au lait stains ( marks ) – NF
- exophthalmia, goiter – hyperthyroidism
- bisexual organs, gynekomastia, the lack of
secondary sexual features in girls,
hirsutism – failure of biosynthesis of
adrenal cortex hormones ( eg CAH )
- hypertrophy of the tonsils – disorders of
night respiratory
Examination - continued
2. Palpable exam:
- big, pulsing fontanel – hydrocephalus
- goiter – hyperthyroidism
- Abnormal abdominal masses – Wilm’s tumor,
hydronephrosis, polycystic kidney disease
3. Auscultation:
- Systolic murmur above aorta and between blade
bones – coarctation of the aorta
- systo-diastolic murmur in abdominal and/or
lumbar area – reno-vascular hypertension
Examination - continued
4. Neurological exam:
- Chwostek and Trousseau syndrome, weakened
tendinous reflex – hyperaldosteronism ( low
Ca, K, high Na )
5. Pulses examination:
- decreased – possibility of intracranial
hypertension
- increased – hyperthyroidism
- normal in the upper limbs and poor or none in
the lower limbs – coarctation of the aorta
Physical examination
- calculation of BMI ( body mass index ) and
WHR ( waist-hip ratio )
- ophthalmogical examination - fundus of the
eye
Diagnostic tests
1. Serum tests:
-creatinine, BUN, ionogram ( sodium, kalium
and calcium )
-lipidogram
-renine serum activity with sodium and
aldosterone urine elimination
2. Urine analysis
Lab test - continued
3. 24-hour urine collection of :
- microalbumines ( to assess glomerulus damage )
- VMA ( vaniline-mandelic acid ), catecholamines to exclude pheochromocytoma/neuroblastoma (
an excess release of catecholamines to the
blood system )
- 17-KS, 17-OHCS - markers of adrenal cortex ( to
assess aderenal cortex abnormality like e.g.
Cushing syndrome ),
- steroid profile ( to exclude steroidogenesis
abnormalities)
Lab test continued
- cortisol profile ( Cushing syndrome )
- TSH, T3 and T4 ( thyroid abnormalities )
- OGTT in every obese child with BMI over
the 85 percentile !!!
- drug screen – when substance abuse is
suspected
Primary hyperaldosteronism ( Conn
syndrome )
is susspected when there is hypertension
with:
- Hypokaliemia ( <3,5mEg/l )
- Increased kalium urine eliminations
is confirmed when:
- Aldosteron activity in urine and blood
is high
- Renine Serum Activity is low.
Primary hyperaldosteronism continued
• Primary hyperaldosteronism – Conn
syndrome can be caused by:
- hypertrophy,
- adenoma,
- carcinoma of adrenal cortex
Primary hyperaldosteronism continued
Symptoms:
- polidypsia, poliuria, weakness of the muscles, cramps (
follow from hypokaliemia)
- Hypertension ( retension of sodium )
Diagnosis:
- scyntygraphy with scintadren
Treatment:
- Spironolacton ( blocker of mineralocorticoids receptors )
- Triamteren, Amilorid – diuretics-severs of kalium
- Ace-inhibitors; rarely Ca-blockers
Hypertension with hyperkaliemia
• Very rare diagnosis of e.g. monogenic
Gordon’s syndrome or it can occure in
polycystic kidney disease.
Additional tests
- Abdominal US with renal assessment and
renal doppler ( the assessment of renal
arteries )
This test should be done in every patient
before initiation of ACE-inhibitor treatment!!!
Bilateral renal artery stenosis is
contraindication for ACE inhibitors !!!
Additional tests continued
- Renoscyntygraphy ( sometimes with captopril test when renovascular hypertension is suspected )
- Miction cystoureterography especially in young children
with history of urinary tract infections or kidney scars
occurring in renoscyntygraphy.
- Echo with assessment of the left ventricular mass and
aortic arch.
- AngioCT, renal arteriography and angioMR of renal
arteries are done when the diseases of renal vessels are
suspected.
- Scyntygraphy with MIBG ( when pheochromocytoma is
suspected ) or with scintadren ( when adrenal cortex
tumour is suspected )
Complications of hypertension
Refers to:
- The heart
- Vessels
- The Brain
- Kidneys
Complications continued
• Heart:
- left ventricular hypertrophy ( IVS
hypertrophy )
- acute heart failure
- systolic heart failure
- chronic heart failure
- myocardial ischemia
Complications - continued
• Vessels:
- increase of peripheral resistance
- remodeling of vessels,
- atherosclerosis
- thrombo-embolic incidents
Complications - continued
Brain:
- acute hypertensive encephalopaty and
oedema of the brain
- TIA ( transient ischemical attacks )
- ischemic and/or haemorrhagic brain
strokes
Complications - continued
Kidney:
- hyperfiltration
- proteinuria
- parenchymal kidney hypertension which
leads to polyuria and metabolic alkalosis
- vascular sclerosis
- increase of uric acid
- chronic kidney disease
Assessment of hypertension
complications
- echo: assessment of the left ventricular mass
- ophtamologic examination: assessment of the
fundus of the eye ( vessels )-hypertensive
retinopathy
- assessment of the kidney’s function: BUN,
creatinine, GFR, microalbuminuria ( damage of
glomerulus vessels and hyperfiltration )
- US doppler: assessment of the thickness of
arteries
Assessment of hypertension
complications
Remember !
The assessment of hypertensive
complications and the risk of
cardiovascular changes is the main
criteria of initiation of the
pharmacological treatment.
Management algorythm of primary
hypertension
1. Measure BP and height and calculate BMI
A - normotensive – educate on healthy lifestyle
B - prehypertensive :
- therapeutic lifestyle changes ( diet, sport etc )
- repeat BP in 6 months
- consider diagnosis workup and evaluation for
organ damage
- if overweight exists – weight reduction
- if no overweight – monitor BP every 6 months
Management algorithm continued
C - stage 1 hypertension - repeat BP over 3
visits – assess organ damages:
- if primary hypertension - therapeutic
lifestyle changes - weight reduction
- if secondary hypertension - specific
diagnostic for the cause
Management algorithm continued
D - stage 2 hypertension - diagnosis
procedure include assessment of organ
changes - consider referral to provider with
expertise in pediatric hypertension:
- if normal BMI- drug treatment
- if overweight – weight reduction and
drug treatment
Hypertension- treatment
At the begining, in every child with
hypertension or RR high normal- non
farmacological treatment is recomanded!
Treatment
When hypotensive treatment is necessary:
1. In conditions with temporary hypertension
2. In secondary hypertension with ineffective or
impossible causal treatment
3. In primary hypertension when ineffective nonpharmacological treatment
Goal of treatment - Blood pressure level less
than the 95th percentile!
In case of coincidence of diabetes and renal
diseases – less than the 90th percentile.
Treatment
There are two methods of treatment:
- non-pharmacological
- pharmacological
Non-pharmacological treatment has particular
meaning in primary hypertension and it is
based on changing lifestyle:
-loss of weight
-physical activity
-modification of a diet ( including limiting of salt
intake )
There is only one contraindication of practice
sport – bad controlled stage 2 hypertension!!
vs.
When to start pharmacological
treatment in primary hypertension
1. In primary hypertension after 6 months
ineffective non-pharmacological treatment (
stage 1 )
2. In stage 2 primary hypertension ( always )
1. In primary hypertension stage 1 with
complications ( eg IVS hypertrophy, changes
on the fundus of the eye ) or/and concomitant
diseases like diabetes , hyperlipidemia
4. In prehypertensive patients with complications
and risk factors like diabetes ( also )
Treatment - continued
Pharmacological:
In children we use almost every kind of
hypotensive drugs, but
ACE-inhibitors and Ca-blockers are the
drugs from the choice!!!
We start treating from monotherapy.
In case of severe and symptomatological
hypertension polytherapy is recommended
( including i.v. intake either )
Hypotensive drugs using in
pediatrics
ACE-inhibitors:
-Enalapril ( Enarenal )
-Lizynopril ( Lisinoratio )
-Ramipril ( Polpril, Ramicor )
-Captopril s.l.
Mechanism of ACE-inhibitors activity:
- Inhibition of RAAS ( with dicrease aldosterone
and increase sodium and dicrease kalium
elimination )
Ace inhibitor are contraindicated in biltateral
stenosis of renal artery!!!
Hypotensive drugs continued
AT1blockers:
-Lozartan ( Lorista )
-Valsartan ( Valzek )
Alfa and beta blockers:
-Labetalol
Beta blockers:
-Atenolol
-Metoprolol ( Metocard, Beatloc ZOK )
-Propranolol
Hypotensive drugs continued
Ca-blockers:
-Amlodipine ( Amlozek )
Diuretics:
-Hydrochlorothiazidum
-Furosemid
-Spironolactone
Hypotensive drugs continued
And also ( rare using in pediatrics ):
-Klonidine ( central alfa-agonist )
-Alfa-blockers: Doksazosyna, prazosyna
-Wasodilatators: Hydralazine, Minoksydil
-Metyldopa
Treatment in urgency and
emergency hypertension
• Hypertensive urgency ( the risk of organ
failure ):
The normalization of the blood pressure in
36-96hrs is needed
Hypertension emergency ( impending organ
failures )
The normalization of the blood pressure in
48-72hrs is needed
Hypertensive urgency-treatment
First 6 hrs – decrease of the blood pressure
for about 30%
Next 36-96hrs – gradually normalization of
the blood pressure
Hypertensive emergency
• Firs 1-2hrs – decreasment the bllod
pressure for about 30%
• Next 24-36hrs – decresement the blood
pressure for another 30%
• Then normallization of the pressure till 7296hrs
Hypotensive drugs using in
urgency and emergency stages
•
•
•
•
•
•
•
Nifedypina – s.l.
Labetalol – i.v.
Sodium Nitroprusyde- i.v
Diazoksyd – i.v.
Hydralazyna – i.v.
Klonidyna – i.v.
Esmolol – i.v.
Treatment of severe hypertensioncontinued
It must be done in the intensive care unit,
with ecg-monitoring, RR-monitoring,
pulsoxymetre monitoring, water balance
and intarvenious access
Monitoring blood pressure in every 15min
until it’s decreased for 30%
Later in every 30-60min
In every patient the fundus of the eye and
neurological state should be assessed.
Healthy lifestyle = no primary
hypertension
Thanks for your attention
What you should know after
presentation
1.
2.
3.
4.
5.
Definition of hypertension and its stages
What is „white-coat” hypertension
When to start checking bp and how often
Main rules of measurement of bp in children
Most common causes of secondary hypertension by age (
newborns, infants and teenagers )
6. Which tests ( blood, urine, additional ) are necessary to
diagnose hypertension and its complications
7. When to start pharmacological treatment and goals of
treatment
8. Which medications are from the choice in pediatrics and
what is the contraindications of ACE-inhibitors.
9. Non-pharmacological methods of hypotensive treatment
10. What is primary hyperaldosteronism (serum markers)