UPDATED GUIDELINES AAP 2017 / I3C CONSORTIUM

1. Hypertension in Children
Dr Adhi Arya
Fellow pediatric cardiology

2. • AHA /AAP guidelines 2017
• The international childhood cardiovascular cohort (i3c)
consortium
• 2016 European society for hypertension guidelines for high BP
in children and adolescents.

3. Key action statements AAP 2017

8. 2 important questions:
(1) What is the rationale for identification and treatment of
hypertension in children ?
(2) How is hypertension in children defined and diagnosed?
In addition, knowledge gaps and research priorities and
recommendations for practice

9. Rationale for identification and treatment
International Childhood Cardiovascular Cohort (I3c) Consortium was
initiated in 2002 and consists of 7 large cohorts in the United
States(5), Finland(1), and Australia(1), brought together to link
childhood cardiovascular risk factors to adults disease
Twelve-thousand cohort members .The majority are now in their
twenties and thirties

10. I3c consortium key evidences
1) Childhood BP, whether normal or high, is strongly predictive of adult
BP, reinforcing the importance of early recognition.
2) LVH, which is strongly associated with hypertension in adults, is an
established, independent risk factor for cardiovascular events.

11. I3c consortium key evidences
3) Elevated BP that persisted from childhood into adulthood was
associated with increased cIMT.
4) Microalbuminuria is a powerful predictor of both renal insufficiency
and cardiovascular morbidity and mortality in adults. The prevalence
of microalbuminuria among children diagnosed with hypertension is
estimated to be 20%.

12. Forthcoming evidence from the i3c consortium
The I3C Consortium has recently received funding for a study to
measure cardiovascular events among all 7 cohorts beginning in 2015
The study, to be completed in 2018, will provide extremely valuable
information, including an estimate of the long- term risk, if any,
conferred by pediatric hypertension, including cardiovascular events,
and potential validation of current BP standards in relation to
cardiovascular events.

13. Indian scenario
The application of international reference to Indian children that differ in various
demographic factors, may not be valid
Higher diastolic pressures for both sexes than international standard across all age
groups.
Higher blood pressure values in Indian population are of considerable public
health significance.
Blood Pressure Distribution in Indian Children, Indian Paediatrics Sep 2009
From the Departments of Pediatric Cardiology and *Biostatistics, Amrita Institute of Medical Sciences and Research Centre,
Kochi, India.

14. Diagnosis
Hypertension in adults is persistent systolic BP ≥130(140) mm
Hg OR diastolic BP ≥80(90) mm Hg.
This is based on outcomes data, such as cardiovascular
morbidity and mortality---Not available for children.
Because BP is approximately normally distributed, they
recommended a threshold of systolic and diastolic BP that is 2
SDs above the mean, or roughly the 95th percentile.

15. Approach used with children defined according to normative
percentiles of BP averaged over 3 occasions.
These percentiles are in turn adjusted for children’s age, sex,
and height percentiles
Whichever of systolic or diastolic BP percentile is higher
defines the BP category

16. • Based on BP categories
• Associated conditions

17. Older classification

19. Previous BP Tables

20. So using these new tables excluding obese children from
pevious tables more children will be labeled as
hypertensive

21. • Based on the 90th
percentile BP for age
and sex at the 5th
percentile of height.
• Which gives the
values in the table a
NPV of >99%.

22. MEASUREMENT
METHODS—AUSCULTATION/ OSCILLOMETRIC DEVICES/ INVASIVE
CUFF SIZE—
OTHER REQUIREMENTS
•Cuff inflated 20 to 30 mmHg above the anticipated systolic BP and
then deflated slowly at a rate of 2 to 3 mmHg per heartbeat
•Prior to BP measurement, stimulant drugs or food should be avoided.
•Measured after five minutes of rest. The child should be seated with
his/her back and feet in a supported position. In infants, -supine
position.
•The right arm is preferred

23. METHODS
•Auscultation remains the recommended method of BP measurement in
children, under most circumstances.
•SBP is determined by the onset of the “tapping” Korotkoff sounds (K1).
fifth Korotkoff sound (K5), or the disappearance of Korotkoff sounds, as the
definition of DBP.
In some children, Korotkoff sounds can be heard to 0 mmHg. Under these
circum- stances, the BP measurement should be repeated with less pressure
on the head of the stethoscope.
Only if the very low K5 persists should K4 (muffling of the sounds) be
recorded as the DBP.

24. Cuff size
• Appropriate cuff size is a cuff with an inflatable bladder width that
is at least 40 percent of the arm circumference at a point midway
between the olecranon and the acromion.
• For such a cuff to be optimal for an arm, the cuff bladder length
should cover 80–100 percent of the circumference of the arm
• Such a requirement demands that the bladder width- to-length ratio
be at least 1:2

26. Inflatable portion- length
Marker to be kept on arm to decide cuff size

27. OSCILLOMETRY VS AUSCULTATION
OSCILLOMETRY
• MAP is determined SBP AND
DBP are calculated
• Calculation formulas are
different for different machines
• Easy to use in infants and
neonates where auscultation is
difficult
• Easier to use where continuous
/repeated monitoring
needed/busy OPD
• Overestimates
• normative data emerging
AUSCULTATION
• SBP and DBP are measured
• Inter-observer variation
• Better predictor of TOD
• Normative data based on it

28. ABPM
•ABPM is useful in reducing over diagnosis of hypertension.
•ABPM is also extremely useful in identifying secondary
hypertension.
•Daytime diastolic BP load >25% plus nocturnal systolic load >50%
have been shown to have 92% specificity for predicting secondary
hypertension.
•In addition, evidence is emerging that ABPM is more useful than
clinic BP in predicting target organ damage.

29. A sufficient number of valid BP recordings are needed for a study to
be considered interpretable.
• Minimum of 1 reading per hour, including during sleep
• At least 40 to 50 readings for a full 24-hour report
The AHA has proposed standards for abnormal ABPM values based
on mean ambulatory systolic BP >95th percentile, combined with
systolic load of 25% to 50% (the percent of systolic measurements
>95th percentile over the entire 24-hour period

30. ABPM carried out over a 24-hour period—portable device attached to
the (non dominant) arm, at 15- to 30-minute intervals during waking
times and every 20 to 60 minutes during sleep. Both systolic BP and
diastolic BP normally decline at night.
BP load is then calculated as the proportion of readings above a
threshold (usually the pediatric 95th percentile).
Dipping is defined as the percentage drop from mean daytime to mean
night-time levels.

33. Limitations of ABPM
• Population-based ABPM values are different
than clinic-based measurements.
• Normative ABPM available -but have been
derived from white German children only,
rather than form more diverse population

35. Management
• Diagnosis
• Evaluate for etiology
• Treatment

36. Evaluation( History/Physical
examinaton/ Investigatons)
• identify secondary hypertension
• identify target-organ damage(LVH,
proteinuria, renal scarring, or retinopathy)
• identify additional cardiovascular
risks(obesity/dyslipidemia/DM)

37. Differentiating Primary and Secondary HT
Primary hypertension
• Adolescents
• Usually stage 1
• Overweight /obese
• Positive family history
• Usually asymtomatic
Secondary hypertension
• Prepubertal
• Usually stage 2
• Diastolic / nocturnal
• May be positive
• Symptoms of underlying
disorder

38. • Based upon the initial history, physical
examination, and laboratory evaluation, --
establish whether the HTN is primary or
secondary.
• Further evaluation --to identify any potentially
reversible cause of secondary HTN.

39. MANAGEMENT
• Non pharmacological measures
• Pharmacological measures

40. Non Pharmacologic Therapy
Recommended for all pts with HT
• Wt reduction in obese pts.
• Regular exercise
• Dietery modification
• Preventing dyslipidemia, avoiding smoking,
alchohol, caffeine , energy drinks
2017 AAP guidelines recommend that
dietary sodium be restricted to
<2300 mg/day. In younger children, the
normal requirement of sodium is
between 2 to 3 mEq/kg per day.
moderate to vigorous activity
for 30 to 60 minutes sessions
for at least 3 to 5 days per
week

41. Pharmacologic therapy
●Symptomatic HTN
●Stage 2 HTN.
●Stage 1 HTN without any evidence of end-organ damage and that persists
despite a trial of four to six months of non-pharmacologic therapy.
●Hypertensive end-organ damage
●Any stage of HTN or high BP for patients with chronic kidney disease (CKD).
●Any stage of HTN for patients with DM

42. Target BP-AAP 2017 guidelines
• Below the 90th percentile or <130/80 in
adolescents (13 years or older)
• CKD -goal of mean arterial BP <50th percentile
based on 24-hour ambulatory blood pressure
monitoring (ABPM)

43. Elevated BP-
Nonpharmacologic therapy-BP to below the 90th percentile
or <130/80 mmHg in adolescents who are 13 years or older.
Stage 1 primary HTN without evidence of end-organ damage or
CVD risk factors,
Nonpharmacologic therapy -target goals are not met within
four to six months after initial therapy (ie, BP below the
90th percentile), pharmacologic therapy is initiated.

44. Stage 1 HTN
Symptomatic or have evidence of end-organ damage or CVD risk
factors, both non-pharmacologic and pharmacologic therapy are
started.
Stage 2 HTN
Both nonpharmacologic and pharmacologic therapy. Patients with
stage 2 HTN and neurologic symptoms including headache, mental
status changes, and neurologic findings should be emergently
evaluated and treated.
Secondary HTN
Therapy directed to the underlying cause, if possible. If the
underlying cause cannot be corrected so that HTN is abolished,
pharmacologic and non-pharmacologic therapy are initiated.

45. Choice of initial drug
• Underlying cause of HTN
• Concurrent disorders
• And the preference and experience of the responsible
clinician

46. Primary HTN
• ACE inhibitor or ARB-except for sexually active females.
• If the target BP goal is not met with the maximum
allowable dose of the initial medication (ACE inhibitor or
ARB), add a thiazide diuretic to the drug regimen.
For sexually active females -CCB be used as the initial
antihypertensive agent
Renovascular Disease-CCB be used as the initial
antihypertensive agent
CKD/DM-ACE inhibitors be used as the initial
antihypertensive agent ARBs are a reasonable alternative.

47. FDA Approved

51. Sports participation
Elevated BP
• May participate in competitive sports.
• Ongoing management includes
nonpharmacologic measures (weight
management, well balanced diet, and
daily physical activity)
• Monitoring of BP every six months.

52. Sports participation
Stage 1 HTN and no evidence of end-organ
injury
• May participate in competitive sports.
• BP checked within one to two weeks after initiation
of competitive sports or sooner if symptomatic.
• Referral to subspecialists with expertise in managing
children with HTN is warranted for children who are
symptomatic, have LVH or concomitant heart disease,
or have persistently elevated BP on two additional
occasions.

54. Stage 2 HTN
• Restricted from high-static sports even if there is no
evidence of end-organ injury.
• These would include sports classified as IIIA to IIIC
• Children with stage 2 HTN, once treated and
documented to be normotensive, may be allowed to
participate in these sports with ongoing monitoring.

55. Summarize
• Pre-hypertension is now elevated BP
• Normative BP tables based on normal-weight , non obese
children
• A simplified screening table for identifying BPs needing
further evaluation
• A simplified BP classification in adolescents ≥13 years of
age

56. • More limited recommendation for screening BP
measurements only at preventive care visits.
• Streamlined recommendations on the initial evaluation and
management of abnormal BPs
• An expanded role for ambulatory BP monitoring
• Recommendations on when to perform echocardiography in
the evaluation of newly diagnosed hypertensive pediatric
patients
• Pharmacological and non pharmacological treatments