The document discusses hypertension in teenage years. It begins with an introduction and overview of the magnitude of the problem. It then defines teenage hypertension and reviews international data on prevalence rates. The document also describes results from screening programs for hypertension and obesity in high schools in Bahrain. It concludes that primary hypertension is increasingly being identified in children and adolescents where it is usually mild and associated with factors like family history and overweight.

1. HYPERTENSION IN
TEENAGE YEARS
Jafar Al-Said. M.B.ChB. MD. FASN. FACP.
Chair of Internal Medicine.
Nephrology and Internal medicine Consultant.
Bahrain Specialist Hospital
Jafar Al-said. Second Gulf Hypertension Conference 27-28/Jan. 2016

2. SCHEME
• Introduction.
• Magnitude of the problem.
• Definition of Teenage HTN.
• International Data.
• Hypertension and obesity screening among High and middle schools in Bahrain.
• Conclusion.
Jafar Al-said. Second Gulf Hypertension Conference 27-28/Jan. 2016

3. 45%
41%
41%
36%
38%
35%
2014 GLOBAL HTN PREVALENCE
HTN GLOBAL
PREVALENCE
39%
Jafar Al-said. Second Gulf Hypertension Conference 27-28/Jan. 2016

4. Jafar Al-Said. Global HTN prevalence during the 21st Century. Poster at ESH 2015. Milano.
The Predicted Increment in Hypertensive Patients During the 21st Century
Assuming a Stable Prevalence of 39% of the Global population
Jafar Al-said. Second Gulf Hypertension Conference 27-28/Jan. 2016

5. DEFINITION OF
TEENAGE
HTN
Jafar Al-said. Second Gulf Hypertension Conference 27-28/Jan. 2016

6. CLASSIFICATION OF PREHYPERTENSION AND HYPERTENSION IN
CHILDREN AND ADOLESCENT
National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and
Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children
and adolescents. May 2005. NIH Publication No. 05-5267.
http: / /www.nhlbi.nih.gov/health/prof/heart /hbp/hbp_ped.pdf. Accessed July 27, 2011.
Measure BP at
each office visit
for > 3 years
age
Jafar Al-said. Second Gulf Hypertension Conference 27-28/Jan. 2016

7. HYPERTENSION IN ADOLESCENTS.
Undiagnosed:
• 75% of the cases of HTN.
• 90% of Prehypertensive
Aglony M, Acevedo M, Ambrosio G - Expert Rev Cardiovasc Ther - December 1, 2009; 7 (12); 1595-603
Jafar Al-said. Second Gulf Hypertension Conference 27-28/Jan. 2016

8. PREVALENCE OF HTN AMONG PEDIATRIC AGE
EDWIN RODRIGUEZ-CRUZ, P SYAMASUNDAR RAO.
• United States Data. Updated July 2015
• 2 – 5% of Children has HTN.
• Gender difference:
 < 6 years similar BP.
 6- puberty slightly higher in girls. till puberty.
 Adolescent males have higher BP.
• Race: No difference in race.
http://emedicine.medscape.com/article/889877-overview
Jafar Al-said. Second Gulf Hypertension Conference 27-28/Jan. 2016

9. PREVALENCE OF HYPERTENSION AND PRE-HYPERTENSION AMONG
ADOLESCENTS
Aim: HTN and PreHTN prevalence in adolescence. school screening population
Results:
• Cross sectional. Houston, Texas.
• N = 6790.
• Age 11-17 years.
• Ht., Wt. and BP. (oscillomertric)
• Repeated BP twice for abnormal BP in different occasions.
• PreHypertensive 15.7%
• HTN 3.2%.
Karen L. McNiece, Timothy S. Poffenbarger, Jennifer L. Turner, Kathy D. Franco, Jonathan M. Sorof, Ronald J.
Portman, Prevalence of Hypertension and Pre-Hypertension among Adolescents. The Journal of Pediatrics Volume
150, Issue 6, June 2007, Pages 640–644.e1
Jafar Al-said. Second Gulf Hypertension Conference 27-28/Jan. 2016

10. PREVALENCE OF HYPERTENSION AND ITS ASSOCIATION WITH OBESITY AMONG
SCHOOL CHILDREN AGED 6-15 LIVING IN SAKARYA PROVINCE IN TURKEY.
Aim: determine the prevalence of HTN and obesity among school aged 6-15.
Results:
• 12 schools randomly selected.
• N = 2166.
• HTN present in 15.15%.
• Obesity present in 18%
Factors associated with HTN:
• Gender and obesity.
• NOT family history.
Önsüz FM, Demir F. Prevalence of hypertension and its association with obesity among school children aged 6-
15 living in Sakarya Province in Turkey. Turk J Med Sci. 2015;45(4):907-12.Jafar Al-said. Second Gulf Hypertension Conference 27-28/Jan. 2016

11. DIN-DZIETHAM R, LIU Y, BIELO MV, SHAMSA F
• National Survey data.
• Non institutionalized population from 1963 – 2002.
• Age 8-17.
Results:
• PreHTN increased 2.3% (p= 0.0003)
• HTN increased by 1% (NS).
• HTN was more among African American and Hispanic.
Din-Dzietham R, Liu Y, Bielo MV, Shamsa F - High blood pressure trends in children and adolescents in national
surveys, 1963 to 2002. Circulation - September 25, 2007; 116 (13); 1488-96
High blood pressure trends in children and adolescents in national
survey, 1963 to 2002.
Jafar Al-said. Second Gulf Hypertension Conference 27-28/Jan. 2016

12. TEENS AT RISK FOR PROGRESSION TO HIGH BP.
DENISE MANN. AMERICAN SOCIETY OF HTN 2006
Aim: rate of progression of BP.
• 8000 adolescent.
• Age 13-15.
• Single BP checked Two years apart.
Results:
• Progression from Prehypertensive to HTN was 7% per year.
• Predictors of HTN:
• Wt. in males.
• Age in females.
http://www.webmd.com/heart-disease/news/20060519/high-blood-pressure-teensJafar Al-said. Second Gulf Hypertension Conference 27-28/Jan. 2016

13. DETERMINANTS OF BP DISTRIBUTION IN SCHOOL CHILDREN.
ANISA M. DURRANI, WASIM FATIMA
Aim:
Determining BP percentile distribution and the association with Anthropometric
parameters in Aligrah (India).
Results:
• N = 701.
• Age group 12-16 years.
• High BP was present in:
• 9.36% of Boys
• 9.46% of girls
Anisa M. Durrani, Wasim Fatima, Determination of BP in School children. European Journal of Public
Health.22,3,369-373
Jafar Al-said. Second Gulf Hypertension Conference 27-28/Jan. 2016

14. HYPERTENSION AND ITS CORRELATES AMONG SCHOOL
ADOLESCENTS IN DELHI
Aim:
Prevalence of HTN among urban adolescent schools.
Association with Anthropometric measurements.
Methodology:
Cross sectional. In Central Delhi.
Results:
N = 315.
Boys 66% (208).
Mean Age 14.1 + 0.96.
HTN 1.6% systolic, 5.4% diastolic.
Prehypertensive4.1% systolic, 26% diastolic.
Tanu Anand, G. K. Ingle, G. S. Meena, Jugal Kishore, and Rajesh Kumar. Hypertension and Its Correlates Among School
Adolescents in DelhiInt J Prev Med. 2014 Mar; 5(Suppl 1): S65–S70.Jafar Al-said. Second Gulf Hypertension Conference 27-28/Jan. 2016

15. PREVALENCE OF HIGH BLOOD PRESSURE IN 122,053 ADOLESCENTS:
A SYSTEMATIC REVIEW AND META-REGRESSION.
Aim:
1. Systematic review of literature for HTN prevalence.
2. Analyze possible factors.
3. Compare the prevalence among developing and developed countries.
Methodology:
55 studies.
Till Aug. 2013.
Results:
N 122,053
Prevalence is:
Total 11.2%.
Boys 13% versus Girls 9.6% P < 0.01
De Moraes AC, Lacerda MB, Moreno LA, Horta BL, Carvalho HBPrevalence of high blood pressure in 122,053 adolescents: a
systematic review and meta-regression. Medicine (Baltimore) - December 1, 2014; 93 (27); e232Jafar Al-said. Second Gulf Hypertension Conference 27-28/Jan. 2016

16. Jafar Al-said. Second Gulf Hypertension Conference 27-28/Jan. 2016

17. ETIOLOGY OF HTN IN TEENAGERS
• Primary HTN is now increasingly identified in Children and adolescent.
• Usually mild form.
• Associated with:
• family history.
• Over wt.
• Metabolic syndrome.
• Secondary HTN is more common.
National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The
fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. May 2005.
NIH Publication No. 05-5267. http: / /www.nhlbi.nih.gov/health/prof/heart /hbp/hbp_ped.pdf. Accessed July 27, 2011
Jafar Al-said. Second Gulf Hypertension Conference 27-28/Jan. 2016

18. ETIOLOGY OF HYPERTENSION
• Renal causes.
• Endocrinal causes.
• Coarctation of the aorta.
• Drug Induced.
• Obstructive sleep apnea.
• Connective Tissue disease.
National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The
fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. May 2005. NIH
Publication No. 05-5267. http: //www.nhlbi.nih.gov/health/prof/heart /hbp/hbp_ped.pdf. Accessed July 27, 2011.
Lurbe E, Cifkova R, Cruickshank JK, et al. Management of high blood pressure in children and adolescents: recommendations of
the European Society of Hypertension. J Hypertens. 2009;27(9):1719-1742.
Jafar Al-said. Second Gulf Hypertension Conference 27-28/Jan. 2016

19. RISK FOR DEVELOPING HTN IN TEENAGER
• Over wt. & obesity.
• Family history of HTN and CV.
• Male gender.
• Maternal smoking.
• Lack of physical activity.
• Smoking.
Breast feeding reduce risk of HTN.
Race and Ethnicity is not associated with risk.
Riley M., Bluham B., High blood pressure in children and adolescents. American Family Physician; Volume 85,
Number 7.April 1, 2012Jafar Al-said. Second Gulf Hypertension Conference 27-28/Jan. 2016

20. HISTORY
• Birth, growth and development history.
• Screening for:
• Urological and renal abnormalities.
• Cardiac.
• Endocrinal.
• Neurological.
• Drugs.
• Sleep pattern.
Jafar Al-said. Second Gulf Hypertension Conference 27-28/Jan. 2016

21. BP CUFF SIZE
Measuring BP:
• Auscultation.
• Confirm the Oscillometric
with Auscultation ( > 90%)
• Rt. Arm supported.
• Arm at heart level.
• Proper size cuff.
• Site quite for 5 min.
• Chair with back support.
• Feet on the ground.
Jafar Al-said. Second Gulf Hypertension Conference 27-28/Jan. 2016

22. BLOOD PRESSURE ANTHROPOMETRIC
CHARTS FOR BOYS.
Jafar Al-said. Second Gulf Hypertension Conference 27-28/Jan. 2016

23. BLOOD PRESSURE ANTHROPOMETRIC
CHARTS FOR Girls.
Jafar Al-said. Second Gulf Hypertension Conference 27-28/Jan. 2016

24. PHYSICAL EXAM
• BMI.
• Growth.
• Difference between the limbs.
• Abdominal Bruits.
• Ambiguous genitalia.
National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The
fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. May 2005.
NIH Publication No. 05-5267. http: / /www.nhlbi.nih.gov/health/prof/heart /hbp/hbp_ped.pdf. Accessed July 27, 2011
Jafar Al-said. Second Gulf Hypertension Conference 27-28/Jan. 2016

25. INVESTIGATION FOR CONFIRMED HYPERTENSIVE
CHILDREN
• CBC.
• Chemistry 6.
• Urine Analysis & Cx.
• FBS.
• Lipids.
• Ultrasound for the kidneys.
• Echocardiography.
If suspected:
• Polysomnography.
• Drug screening.
National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and adolescents. The
fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. May 2005. NIH
Publication No. 05-5267. http: / /www.nhlbi.nih.gov/health/prof/heart /hbp/hbp_ped.pdf. Accessed July 27, 2011.Jafar Al-said. Second Gulf Hypertension Conference 27-28/Jan. 2016

26. TARGET ORGAN DAMAGE
• LVH is preset in 34-38% of children with mild HTN. (64-66)
• Echo is recommended in all HTN children.
• Increased Carotid intimal thickness. (60)
• Reversible retinopathy reported in 50% of HTN children. (69)
Jafar Al-said. Second Gulf Hypertension Conference 27-28/Jan. 2016

27. ABPM IN TEENS
• Confirm border line BP.
• Discrepancy between home and office.
• White coat HTN “present in 53% of teens”
Lurbe E, Sorof JM, Daniels SR. Clinical and research aspects of ambulatory blood pressure monitoring in children. J Pediatr.
2004;144(1):7-16.
Sorof JM, Portman RJ. White coat hypertension in children with elevated casual blood pressure. J Pediatr. 2000;137(4):493-
497.
Jafar Al-said. Second Gulf Hypertension Conference 27-28/Jan. 2016

28. SYSTOLIC AND DIASTOLIC AMBULATORY BLOOD PRESSURE
(SYSTOLIC/DIASTOLIC) VALUES FOR CLINICAL USE
Lurbe et al. Management of high blood pressure in children and adolescents: recommendations of the European
Society of HypertensionJournal of Hypertension 2009, Vol 27 No 9. 1719-1742
Jafar Al-said. Second Gulf Hypertension Conference 27-28/Jan. 2016

29. MANAGEMENT OF BP
Target BP.
• No target organ damage < 95th centile.
• With Target organ Damage <90th centile.
National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and adolescents. The
fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. May 2005. NIH
Publication No. 05-5267. http: / /www.nhlbi.nih.gov/health/prof/heart /hbp/hbp_ped.pdf. Accessed July 27, 2011.
Jafar Al-said. Second Gulf Hypertension Conference 27-28/Jan. 2016

30. MANAGEMENT OF BP
1- Lifestyle.
2- Medications.
Jafar Al-said. Second Gulf Hypertension Conference 27-28/Jan. 2016

31. LIFESTYLE MANAGEMENT
• Wt. Reduction.
• Daily Na. intake:
1.2gm/day 4-8 years
1.5gm > 8 years
• Regular Exercise.
• Healthy Diet.
• Avoid Tobacco and Alcohol.
• Family counseling for diet and physical activities.
U.S. Preventive Services Task Force. Screening for obesity in children and adolescents. January 2010.
http://www.uspreventiveservicestaskforce. org/uspstf/uspschobes.htm. Accessed January 20, 2011.
Klatsky AL, Friedman GD, Siegelaub AB, Gérard MJ. Alcohol consumption and blood pressure Kaiser-Permanente Multiphasic
Health Examination data. N Engl J Med. 1977;296(21):1194-1200.
Jafar Al-said. Second Gulf Hypertension Conference 27-28/Jan. 2016

32. INDICATION FOR ANTIHYPERTENSIVE DRUGS
• Symptomatic HTN.
• Secondary HTN.
• Target organ damage.
• DM I & II.
• Persistent HTN despite lifestyle.
NIH Publication No. 05-5267. Revised May 2005
Jafar Al-said. Second Gulf Hypertension Conference 27-28/Jan. 2016

33. RECOMMENDED INITIAL DOSES FOR SELECTED ANTIHYPERTENSIVE AGENTS FOR THE
MANAGEMENT OF HYPERTENSION IN CHILDREN AND ADOLESCENTS
Lurbe et al. Management of high blood pressure in children and adolescents: recommendations of the European
Society of Hypertension. Journal of Hypertension 2009, Vol 27 No 9. 1719-1742Jafar Al-said. Second Gulf Hypertension Conference 27-28/Jan. 2016

34. • National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the
diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. May 2005. NIH Publication No. 05-5267. http: /
/www.nhlbi.nih.gov/health/prof/heart /hbp/hbp_ped.pdf. Accessed July 27, 2011.
• Lurbe E, Cifkova R, Cruickshank JK, et al. Management of high blood pressure in children and adolescents: recommendations of the European Society of
Hypertension. J Hypertens. 2009;27(9):1719-1742.
Medical Therapy
Jafar Al-said. Second Gulf Hypertension Conference 27-28/Jan. 2016

35. N = 2594
Boys 1268
Girls 1326
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37. CONCLUSION
• Hypertension has a high Global Burden.
• Shifting the resources and efforts towards prevention is recommended.
• One third of the screened school sample had abnormal BP.
• Males have higher BP.
• The independent variables correlated with BP were:
• Age.
• Gender
• BMI.
• Pulse.
• The nationality and school correlation with BP needs further studies.
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44. BRITISH SCHOOL BAHRAIN
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