This document summarizes the key changes in the 2017 AAP Guidelines for Hypertension compared to the 2004 guidelines. Some of the major changes include replacing the term "prehypertension" with "elevated blood pressure", using new normative BP tables based only on normal-weight children, simplifying screening and classification of BP in adolescents, expanding the role of ambulatory blood pressure monitoring (ABPM), revising recommendations on echocardiography and defining left ventricular hypertrophy (LVH), and lowering treatment goals for primary hypertension and hypertension with chronic kidney disease (CKD). The guidelines place more emphasis on lifestyle modifications and aligning pediatric hypertension definitions and management with adult guidelines.

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2017 AAP Guidelines For Hypertension: Highlights
Ibrahim Sandokji

2. S L I D E 1
September 2017

3. S L I D E 2
Rationale
• 13 years since the 2004 Forth Report
• Significant increase in interest in
childhood HTN
• Large number of studies on pediatric
HTN:
– Increase in prevalence of high BP
– 3.5% with HTN
– 10-11% with elevated BP
– Increase prevalence of obesity leading to
HTN
– High BP in childhood correlate with adult
HTN and CVD

4. S L I D E 3
Evidence-based Methodology
• PICO-T questions used for
literature search
• Review of ~15,000 articles
• Level of evidence
determined based on AAP
grading matrix
• 30 Key Action Statements
generated

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Main Changes
• Replacement of the term “prehypertension”
with the term “elevated blood pressure
• New normative BP tables based on normal-
weight children
• Simplified screening table
• Simplified BP classification in adolescents
≥13 years of age that aligns with the AHA
and ACC adult guidelines
• Screening BP measurements only at
preventive care visits
• Expanded role for ABPM
• Revised recommendations on
echocardiography and definition of LVH
• Lower treatment goals for primary HTN
and HTN with CKD

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Definition of HTN

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New BP Tables
• 4th report included children with obesity & overweight
• New tables are based only on normal weight children
• 2-4 mmHg lower cutoffs

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• 2017 AAP Guidelines 2004 4th Report

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Simplified Screening Tables
• Based on the 90th percentile BP
values for 5th height percentile
• High negative predictive value

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Key Action Statements

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• KAS 1:
– BP should be measured annually in children and adolescents ≥3 years
of age (only the WCC)
• KAS 2:
– BP should be checked in all children and adolescents ≥3 years of age at
every health care encounter if they have obesity, are taking
medications known to increase BP, have renal disease, a history of
aortic arch obstruction or coarctation, or diabetes
• KAS 3:
– Trained health care professionals in the office setting should make a
diagnosis of HTN if a child or adolescent has auscultatory-confirmed
BP readings ≥95th percentile at 3 different visits

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• KAS 5:
– Oscillometric devices may be used for BP screening in children and
adolescents. When doing so, providers should use a device that has
been validated in the pediatric age group. If elevated BP is suspected
on the basis of oscillometric readings, confirmatory measurements
should be obtained by auscultation.

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ABPM
• ABPM considered “useful” in 4th Report
• Data support ABPM, compared to clinic-measure BP, is:
– More accurate in diagnosing HTN
– More predictive of future BP
– Can assist in detection of secondary HTN
– Correlate more with LVH
– More cost-effective
• Almost 50% of children evaluated for elevated BP have White Coat
HTN (WCH)
• Masked HTN
– Normal office BP but elevated BP on ABPM
– Overall prevalence of 5.8%
– Higher risk with obesity and secondary HTN, such as CKD or aortic
coarctation

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• KAS 6:
– ABPM should be performed for confirmation of HTN in children and
adolescents with office BP measurements in the elevated BP
category for 1 year or more or with stage 1 HTN over 3 clinic
visits.
• KAS 7:
– Routine performance of ABPM should be strongly considered in
children and adolescents with high-risk conditions (e.g. CKD,
DM, obesity) to assess HTN severity and determine if abnormal
circadian BP patterns are present, which may indicate increased risk
for target organ damage
• KAS 8:
– Children and adolescents with suspected WCH should undergo
ABPM. Diagnosis is based on the presence of mean SBP and DBP
<95th percentile and SBP and DBP load <25%.

17. S L I D E 16
Primary vs Secondary HTN
• Primary HTN is now the predominant
diagnosis for hypertensive children and
adolescents in the United States
• KAS 11:
– Children and adolescents ≥6 y of age do
not require an extensive evaluation for
secondary causes of HTN if they have a
positive family history of HTN, are
overweight or obese, and/or do not
have history or physical examination
findings suggestive of a secondary cause
of HTN

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Echocardiography
• LVH in 30-40% of children with primary HTN
• LVH increase CV complications
• 4th Report recommend Echo at time of diagnosis
• KAS 15-1:
– It is recommended that echocardiography be performed to assess for
cardiac target organ damage (LV mass, geometry, and function) at the
time of consideration of pharmacologic treatment of HTN.

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• KAS 15-3:
– Repeat echocardiography may be performed to monitor improvement
or progression of target organ damage at 6- to 12-mo intervals.
Indications to repeat echocardiography include persistent HTN
despite treatment, concentric LV hypertrophy, or reduced LV
ejection fraction
• KAS 15-4:
– In patients without LV target organ injury at initial echocardiographic
assessment, repeat echocardiography at yearly intervals may be
considered in those with stage 2 HTN, secondary HTN, or
chronic stage 1 HTN incompletely treated (noncompliance or
drug resistance) to assess for the development of worsening LV target
organ injury

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LVH definition
• Based on the American Society of Echocardiography
guidelines
• KAS 15-2:
– LVH should be defined as LV mass >51 g/m2.7 (boys and girls) for
children and adolescents older than age 8 y and defined by LV mass
>115 g/BSA for boys and LV mass >95 g/BSA for girls.

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Renal Ultrasonography
• KAS 16:
– Doppler renal ultrasonography may be used as a noninvasive screening
study for the evaluation of possible RAS in normal-wt children and
adolescents ≥8 y of age who are suspected of having renovascular
HTN and who will cooperate with the procedure.

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Overall Treatment Goals
• In the 4th Report, HTN treatment goals in a non-CKD or DM is <95
percentile
• Evidence showed end organ damage markers (e.g. LVMI) were
detected in children with BP <95 percentile and <90 percentile
• KAS 19:
– In children and adolescents diagnosed with HTN, the treatment goal
with nonpharmacologic and pharmacologic therapy should be a
reduction in SBP and DBP to <90th percentile and <130/80
mm Hg in adolescents ≥ 13 years old

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Lifestyle Interventions
• KAS 20:
– At the time of diagnosis of elevated BP or HTN in a child or adolescent,
clinicians should provide advice on the DASH diet (The Dietary
Approaches to Stop Hypertension) and recommend moderate to
vigorous physical activity at least 3 to 5 d per week (30–60 min
per session) to help reduce BP

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Pharmacological Treatment
• Use antihypertensive agents if
– Patient failed 6 months of lifestyle changes
– Symptomatic HTN
– Stage 2 without a clear modifiable risk factor (e.g. obesity)
• 1st line agents include:
– ACEI or ARB
– CCB
– Thiazide diuretic

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• Repeated BP reading every 2-4 weeks
• If still high, can increase the dose till reach maximum or develop
side effect
• Then, add a second agent
• Thiazide diuretic is preferred (salt and water retention from other
antihypertensive)
• BB are not recommended as 1st line (wide side effect profile)

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• In CKD or diabetes:
– ACEI or ARB
• In African Americans:
– higher initial dose of ACEI (don’t respond well to low initial doses)
– CCB
– Thiazide diuretic

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KAS 23: CKD
• Children and adolescents with CKD should be evaluated for HTN at
each medical encounter
• Children or adolescents with both CKD and HTN should be treated
to lower 24-hr MAP <50th percentile by ABPM
• Regardless of apparent control of BP with office measures, children
and adolescents with CKD and a history of HTN should have BP
assessed by ABPM at least yearly to screen for MH

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Major Point
• Changes in HTN definition and alignment with adult
guidelines
• Revised BP tables and screening tools
• More emphasis on ABPM use
• Lower overall treatment goals

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Discussion