Is the SPRINT Blood Pressure Treatment Target of 120/80 mm Hg Relevant for Children?
2016; Lippincott Williams & Wilkins; Volume: 67; Issue: 5 Linguagem: Inglês
10.1161/hypertensionaha.116.06934
ISSN1524-4563
AutoresBonita Falkner, Samuel S. Gidding,
Tópico(s)Hormonal Regulation and Hypertension
ResumoHomeHypertensionVol. 67, No. 5Is the SPRINT Blood Pressure Treatment Target of 120/80 mm Hg Relevant for Children? Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessResearch ArticlePDF/EPUBIs the SPRINT Blood Pressure Treatment Target of 120/80 mm Hg Relevant for Children? Bonita Falkner and Samuel S. Gidding Bonita FalknerBonita Falkner From the Departments of Medicine and Pediatrics (B.F.), Thomas Jefferson University, Philadelphia, PA; and Department of Pediatrics, Nemours/A.I. DuPont Hospital for Children, Wilmington, DE (S.S.G.). and Samuel S. GiddingSamuel S. Gidding From the Departments of Medicine and Pediatrics (B.F.), Thomas Jefferson University, Philadelphia, PA; and Department of Pediatrics, Nemours/A.I. DuPont Hospital for Children, Wilmington, DE (S.S.G.). Originally published28 Mar 2016https://doi.org/10.1161/HYPERTENSIONAHA.116.06934Hypertension. 2016;67:826–828Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2016: Previous Version 1 The Systolic Blood Pressure Intervention Trial (SPRINT), conducted on older adults with markedly elevated risk for cardiovascular events, demonstrated significant outcome benefit with treatment of blood pressure (BP) to a goal of ≤120/80 mm Hg.1 Results of the SPRINT trial would not seem generalizable to children and adolescents because the SPRINT focus was on older adults at high risk for cardiovascular events. Inclusion criteria for sprint were elevated BP and additional high-risk criteria including Framingham risk score >15%, prior cardiovascular disease, reduced glomerular filtration rate, or age >75 years. This trial seems far removed from a pediatric setting. However, the relevance of SPRINT, when one considers pediatric prevention, is that hypertension accelerates cardiovascular disease. With the exception of age, SPRINT inclusion criteria are often consequences of long-standing hypertension. The success of SPRINT raises the question of whether there is benefit from lifelong BP 140/90 mm Hg, thus supporting pharmacological treatment for primary prevention of cardiovascular events. Based on a body of epidemiological data demonstrating a rise in cardiovascular risk beginning at a BP level ≥120/80 mm Hg, the Joint National Commission 7 (JNC7) guidelines on hypertension in adults introduced the concept of prehypertension for BP levels from 120/80 to 139/89 mm Hg. The intent was to alert patients to modify lifestyle behaviors to prevent further rise in BP.2There are no data that link a BP threshold in childhood with cardiovascular events decades later in adulthood. Children have lower BP than adults. BP levels in children increase with age, and by early to midadolescence, the likelihood of a child meeting the JNC VII criteria for prehypertension passes 10%.3 Beginning in the 1970s, hypertension in childhood has been defined statistically as BP levels that exceed the 95th percentile of the normative BP distribution. The 95th percentile was a conservative estimate of high BP in childhood that was originally intended to enable detection of children with secondary hypertension.4 The 95th percentile is well below the conventional adult threshold defining hypertension of 140/90 mm Hg especially in younger children. Using the criteria of BP level ≥95th percentile on repeated measurement, the prevalence childhood hypertension is ≈3.5% and includes primary as well as secondary hypertension.5,6 Prehypertension in childhood was defined as systolic or diastolic BP ≥90th percentile and <95th percentile. Beginning at 12 years of age, systolic BP levels at the 90th percentile are greater than the adult prehypertension threshold of 120 mm Hg. To be consistent with the adult definition, prehypertension in adolescence was adjusted to BP ≥120/80 to <95th percentile from age 12 years through adolescence.3 Thus, 120/80 mm Hg became an easy BP number to remember and also a BP level that defined some level of risk.The normal rise in BP in childhood is related to growth as well as age. Reference tables that provide the BP value for the 90th, and 95th percentile are determined by sex, age, and height in childhood. These tables are complex and cumbersome to use, especially in primary pediatric care. Although BP measurement has become routine in pediatric health encounters, because of the complexity of the BP reference tables, abnormal BP levels are frequently not identified in asymptomatic children and adolescents.6–8 It would be a great advantage to have a single number as a BP threshold to separate children with normal BP and from those for whom the BP tables should be consulted.Another new recommendation in the 2004 childhood BP guidelines was the recommendation that evaluation of a child with confirmed hypertension also include an evaluation for target organ damage.3 Subsequent clinical studies reported echocardiographic evidence of left ventricular hypertrophy in a substantial portion of hypertensive children and adolescents.9,10 Evidence for target organ damage in hypertensive youth now includes vascular stiffness and increased carotid intimal thickness.11 Moreover, left ventricular hypertrophy has also been reported in adolescents with prehypertension.12,13 In addition, there is emerging evidence that obesity in childhood also contributes to increases in cardiac mass that are in addition to BP level.12,14 These reports call attention to the fact that a BP level of 120/80 mm Hg in adolescence may already be associated with early cardiovascular target organ damage. Based on recent BP data on children and adolescents from the National Health and Nutrition Examination Surveys, ≈10% of adolescents enter young adulthood with a BP ≥120/80 mm Hg.15The importance of BP of 120 to 139/80 to 89 mm Hg measured at age 18 to 30 years for the development of cardiovascular target organ damage in middle age has been emphasized in the Coronary Artery Risk Development in Young Adults study. When coronary artery calcium assessed on computerized tomography scan and left ventricular structure and function measured by echocardiography were assessed in middle age, strong predictors of target organ damage were BP and other risk factors measured at 18 to 30 years. Chronic exposure over the next 20 to 25 years to elevated BP and other risk factors contributed to worsening of target organ injury.16–18The relationship between childhood BP and BP status in young adulthood was further delineated in an analysis of data from the Dunedin Multidisciplinary Health and Development Study, a prospective cohort study that included periodic BP and other risk factor measurements from age 7 to 38 years. Four distinct BP trajectory groups were identified according to BP status at age 38 years; normal, high-normal, prehypertensive, and hypertensive. The hypertensive trajectory had the highest BP levels in childhood, and the prehypertensive trajectory had the next highest childhood BP levels, with systolic BP levels above 120 mm Hg in adolescence. For those with normal and high-normal BP at age 38 years, systolic BP throughout childhood and adolescence was below 120 mm Hg. An increase in body mass index was found to be significantly associated with an upward shift in all 4 BP trajectory groups.19The above trajectory data and emerging evidence on BP-associated target organ damage in youth, as well as population genetic studies20 support a paradigm shift on the approach to childhood BP from primary prevention to primordial prevention. If primary prevention is intervention to lower BP to prevent cardiovascular events, then primordial prevention would be interventions to prevent development of prehypertension/hypertension in childhood and lower BP levels would extend into early-mid adulthood. There are BP risk factors that are modifiable for primordial prevention. The longitudinal relationship between overweight/obesity in youth and future hypertension has been well understood for many years.21,22 Physical activity in youth and physical fitness in young adulthood blunt the rise in BP with age and are associated with reduced likelihood of future hypertension.23,24 Because of secular changes in dietary patterns, dietary sodium intake in childhood is far above recommended levels. Reports from analysis of recent National Health and Nutrition Examination Surveys data demonstrate a positive association of sodium intake with BP in childhood.25 There is also an independent effect of sodium intake, as well as body mass index and waist circumference, on the increasing trend in childhood BP levels.26 These findings indicate potential BP benefits of reducing excessive sodium intake.If prehypertension in young individuals is the threshold for target organ damage and likely sets the stage for a higher BP trajectory, then primordial prevention should focus on conserving normal BP. A normal (optimal) BP for adolescents is <120/80 mm Hg. Based on child BP percentile tables, <110/70 mm Hg is likely an optimal BP for children 75 years.DisclosuresNone.FootnotesThe opinions expressed in this editorial are not necessarily those of the editors or of the American Heart Association.Correspondence to Bonita Falkner, Thomas Jefferson University, 833 Chestnut St. Ste.700, Philadelphia, PA 19107. E-mail [email protected]References1. Sprint Research Group. A randomized trial of intensive versus standard blood-pressure control.N Engl J Med. 2015; 373:2103–2116.CrossrefMedlineGoogle Scholar2. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL, Jones DW, Materson BJ, Oparil S, Wright JT, Roccella EJ; Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. National Heart, Lung, and Blood Institute; National High Blood Pressure Education Program Coordinating Committee. 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