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New American Academy of Pediatrics Hypertension Guideline

2018; Lippincott Williams & Wilkins; Volume: 73; Issue: 1 Linguagem: Inglês

10.1161/hypertensionaha.118.11819

1524-4563

Marc B. Lande, Donald L. Batisky,

Cardiovascular and exercise physiology

HomeHypertensionVol. 73, No. 1New American Academy of Pediatrics Hypertension Guideline Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBNew American Academy of Pediatrics Hypertension GuidelineWho Is Up and Who Is Down Marc B. Lande and Donald L. Batisky Marc B. LandeMarc B. Lande Correspondence to Marc Lande, Department of Pediatrics, University of Rochester, 601 Elmwood Ave, Box 777, Rochester, NY 14642. Email E-mail Address: [email protected] From the Department of Pediatrics, University of Rochester, NY (M.B.L.) and Donald L. BatiskyDonald L. Batisky Department of Pediatrics, Emory University, Atlanta, GA (D.L.B.). Originally published5 Nov 2018https://doi.org/10.1161/HYPERTENSIONAHA.118.11819Hypertension. 2019;73:31–32Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: November 5, 2018: Ahead of Print See related article, pp 148–152The definition of hypertension in adults is based on the level of blood pressure (BP) resulting in increased cardiovascular events and mortality.1 However, because hypertension-associated events, such as myocardial infarction and stroke, occur in later decades, the definition of hypertension in children is instead by convention based on comparison to reference data from the normal distribution of BP in healthy children and adolescents.2 Such reference range data have allowed estimates of the prevalence of hypertension in children and adolescents and have been essential in the formulation of national consensus guidelines for the identification, evaluation, and management of elevated BP in youth.In September 2017, the American Academy of Pediatrics (AAP) published the new Clinical Practice Guideline (AAP CPG) for screening and management of high BP in children and adolescents,3 an update to the 2004 Fourth Report on the Diagnosis, Evaluation, and Treatment of High BP in Children and Adolescents.4 The Fourth Report included normative BP tables and defined hypertension as average BP ≥95th percentile for age, sex, and height on ≥3 occasions. However, the Fourth Report normative BP tables included data from overweight and obese children, potentially increasing thresholds for elevated BP and possibly leading to the underdiagnosis of hypertension. The recent AAP CPG includes new normative pediatric BP tables based on normal-weight children only. Among other changes, the AAP CPG also includes a simplified BP classification in adolescents ≥13 years of age that aligns with the recently released American Heart Association and American College of Cardiology adult BP guidelines.1 In children 22 000 children aged 10 to 17 years screened at 28 different middle and high schools between 2000 and 2017. Participants had 2 to 3 oscillometric BP measurements at the initial assessment. All subjects with BP ≥90th percentile or ≥120/80 mm Hg on the initial screening day subsequently had repeated BP measurements on up to 2 additional occasions. Therefore, an important strength of the report by Bell et al6 is that hypertension prevalence estimates are based on BP measurements on >1 occasion. BPs for all participants at each screen were classified by both Fourth Report guidelines and the AAP CPG. The investigators found that overall the prevalence of elevated BP increased by 1.5% (from 14.8% to 16.3%) using the AAP CPG and that the prevalence of hypertension remained similar to Fourth Report levels, at 2% to 4%. The authors underscore that the assumption that all AAP CPG hypertension thresholds are lower than Fourth Report thresholds because of the exclusion of overweight and obese normative data is incorrect. Instead, the impact of the AAP CPG on the prevalence of elevated BP and hypertension depends largely on the child's age. Youth <13 years old tend to have a higher prevalence of both elevated BP and hypertension while older adolescents have a higher prevalence of hypertension. By contrast younger teens, aged 13 to 15 years, tend to have a higher prevalence of elevated BP but less hypertension.Others have also examined the impact of the AAP CPG on the prevalence of and detection of the consequences of hypertension. Khoury et al7 reported on the clinical impact of using the AAP CPG in 364 youth participating in a study of the cardiovascular effects of obesity and type 2 diabetes mellitus. By design 59% of the subjects were obese, and the average age was 14.9 years. They found that the prevalence of hypertension was 13% by AAP CPG criteria compared with only 8% using Fourth Report thresholds. Although BP was measured on only one occasion, their finding underscores that patients who are obese and older will be more likely to be categorized as hypertensive under the newer AAP guideline. They also found that the new guideline was more sensitive to the identification of target-organ damage in hypertensive patients. In particular, the proportion of participants with left ventricular hypertrophy categorized as hypertensive increased from 20% to 31% using the AAP CPG rather than the Fourth Report.Jackson et al8 reported an analysis of the prevalence of hypertension using AAP CPG and Fourth Report BP thresholds in US youth participating in the 2001 to 2016 National Health and Nutrition Examination Survey. Although the prevalence of hypertension declined in this time period by both the new and former guidelines, they found that there was a weighted net estimated increase of 795 000 youth being reclassified as having hypertension employing AAP CPG using 2013 to 2016 data. Youth who were older, male and those with obesity accounted for most of the people reclassified as having hypertension. In a similar report of National Health and Nutrition Examination Survey participants from 1999 to 2014, Sharma at el9 reported that applying AAP CPG increased the prevalence of elevated BP from 11.8% to 14.2% and also increased the number of children with hypertension or worsening in clinical stage to 5.8%. However, prevalence rates based on National Health and Nutrition Examination Survey data may be overestimates as hypertension categorization is based on BP measured on a single occasion rather than ≥3 occasions as required for the clinical diagnosis of hypertension in children.Taken together, these reports indicate that older adolescent males who are taller and younger boys who are shorter, and youth with obesity, are more likely to be classified as hypertensive using the AAP CPG. Similar but attenuated trends are noted for girls.6 However, the clinical implications of this shift in the categorization of hypertension remain unclear. Neither the Fourth Report nor the new AAP CPG defines hypertension in youth according to associated cardiovascular outcomes, either long-term cardiovascular events or intermediate hypertensive target-organ damage as a surrogate for longer-term outcomes. Therefore, current guidelines for the management of hypertension in youth remain more consensus-based rather than evidence-based. It is now well established that hypertensive target-organ damage is common during youth itself. Hopefully current10 and future research to determine the level of BP elevation that leads to an increased incidence of target-organ damage, and, therefore, presumably heightened long-term cardiovascular risk, will allow future pediatric hypertension management guidelines to be predominantly outcomes based.Sources of FundingNone.DisclosuresM.B. Lande and D.L. Batisky have been coauthors with Dr Joshua Samuels on previous articles. M.B. Lande and D.L. Samuels are currently coinvestigators on the SHIP AHOY (Study of High Blood Pressure in Pediatrics: Adult Hypertension Onset in Youth Study).FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Correspondence to Marc Lande, Department of Pediatrics, University of Rochester, 601 Elmwood Ave, Box 777, Rochester, NY 14642. Email [email protected]rochester.eduReferences1. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.Hypertension. 2018; 71:e13–e115. doi: 10.1161/HYP.0000000000000065LinkGoogle Scholar2. Falkner B. Blood pressure norms and definitions of hypertension in children.Flynn JT, Ingelfinger JR, Portman RJ, eds. In: Pediatric Hypertension. 3rd ed. New York, NY: Humana Press; 2013:141–152.Google Scholar3. Flynn JT, Kaelber DC, Baker-Smith CM, et al; Subcommittee on Screening and Management of High Blood Pressure in Children. Clinical practice guideline for screening and management of high blood pressure in children and adolescents.Pediatrics. 2017; 140:e20171904. doi: 10.1542/peds.2017-1904CrossrefMedlineGoogle Scholar4. 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.Pediatrics. 2004; 114(2suppl 4th Report):555–576.CrossrefMedlineGoogle Scholar5. Lurbe E, Litwin M, Pall D, Seeman T, Stabouli S, Webb NJA, Wühl E; Working Group of the 2016 European Society of Hypertension Guidelines for the Management of High Blood Pressure in Children and Adolescents. Insights and implications of new blood pressure guidelines in children and adolescents.J Hypertens. 2018; 36:1456–1459. doi: 10.1097/HJH.0000000000001761CrossrefMedlineGoogle Scholar6. Bell CS, Samuel JP, Samuels JA. Prevalence of hypertension in children: applying the new American Academy of Pediatrics clinical practice guideline.Hypertension. 2018; 73:148–152. doi: 10.1161/HYPERTENSIONAHA.118.11673LinkGoogle Scholar7. Khoury M, Khoury PR, Dolan LM, Kimball TR, Urbina EM. Clinical implications of the revised AAP pediatric hypertension guidelines.Pediatrics. 2018; 142(2):e20180245. doi: 10.1542/peds.2018-0245CrossrefMedlineGoogle Scholar8. Jackson SL, Zhang Z, Wiltz JL, Loustalot F, Ritchey MD, Goodman AB, Yang Q. Hypertension among youths - United States, 2001-2016.MMWR Morb Mortal Wkly Rep. 2018; 67:758–762. doi: 10.15585/mmwr.mm6727a2CrossrefMedlineGoogle Scholar9. Sharma AK, Metzger DL, Rodd CJ. Prevalence and severity of high blood pressure among children based on the 2017 American Academy of Pediatrics guidelines.JAMA Pediatr. 2018; 172:557–565. doi: 10.1001/jamapediatrics.2018.0223CrossrefMedlineGoogle Scholar10. Mendizabal B, Urbina EM, Becker R, Daniels SR, Falkner BE, Hamdani G, et al. SHIP-AHOY (Study of High Blood Pressure in Pediatrics: Adult Hypertension Onset in Youth): rationale, design, and methods.Hypertension. 2018; 72:625–631. doi: 10.1161/HYPERTENSIONAHA.118.11434LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Fan H and Zhang X (2020) Difference in hypertension prevalence applying three childhood hypertension management guidelines in a national cohort study, Journal of Human Hypertension, 10.1038/s41371-020-00447-7, 35:11, (1038-1045), Online publication date: 1-Nov-2021. January 2019Vol 73, Issue 1 Advertisement Article InformationMetrics © 2018 American Heart Association, Inc.https://doi.org/10.1161/HYPERTENSIONAHA.118.11819PMID: 30571567 Originally publishedNovember 5, 2018 PDF download Advertisement SubjectsHypertension