Aligning Adult and Pediatric Blood Pressure Guidelines
2019; Lippincott Williams & Wilkins; Volume: 73; Issue: 5 Linguagem: Inglês
10.1161/hypertensionaha.119.12653
ISSN1524-4563
AutoresSamuel S. Gidding, Paul K. Whelton, Robert M. Carey, Joseph T. Flynn, David C. Kaelber, Carissa M. Baker‐Smith,
Tópico(s)Cardiovascular Syncope and Autonomic Disorders
ResumoHomeHypertensionVol. 73, No. 5Aligning Adult and Pediatric Blood Pressure Guidelines Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBAligning Adult and Pediatric Blood Pressure Guidelines Samuel S. Gidding, Paul K. Whelton, Robert M. Carey, Joseph Flynn, David C Kaelber and Carissa Baker-Smith Samuel S. GiddingSamuel S. Gidding Correspondence to Samuel S. Gidding, 1631 Hale Hollow Rd, Bridgewater Corners, VT 05035. Email E-mail Address: Samuel.gidd[email protected] From the Familial Hypercholesterolemia Foundation, Pasadena, CA (S.S.G.) , Paul K. WheltonPaul K. Whelton Show Chwan Professor of Global Public Health, Tulane University, New Orleans, LA (P.K.W.) , Robert M. CareyRobert M. Carey University of Virginia, Charlottesville (R.M.C.) , Joseph FlynnJoseph Flynn Division of Nephrology, University of Washington, Seattle Children's Hospital, Seattle (J.F.) , David C KaelberDavid C Kaelber Internal Medicine, Pediatrics, and Population and Quantitative Public Health Sciences, Case Western Reserve University, Cleveland, OH (D.C.K.) and Carissa Baker-SmithCarissa Baker-Smith University of Maryland School of Medicine, Baltimore (C.B.-S.). Originally published1 Apr 2019https://doi.org/10.1161/HYPERTENSIONAHA.119.12653Hypertension. 2019;73:938–943Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: April 1, 2019: Ahead of Print As part of the process of developing the 2017 American College of Cardiology/American Heart Associations (ACC/AHA) and American Academy of Pediatrics (AAP) Hypertension guidelines, it was resolved to assure that recommendations for hypertension evaluation and treatment be consistent across the transition from adolescence to adulthood.1,2 The ACC/AHA Task Force appointed one of its members (S. Gidding) to be a liaison to the writing groups for both of the guidelines and to assist with the development process. The purpose of this paper is to describe that process and to underscore areas of agreement and disagreement between the 2 guidelines. Formal aspects of the process included periodic conference calls (attended by staff leadership for each guideline, the liaison, and key writing group members), establishment of confidentiality agreements regarding guideline content so that subject matter could be shared, and participation in review processes during the finalization of both documents before publication. In face-to-face meetings and email communications of each panel, the liaison was able to share content between the committees facilitate the process and resolve potential discrepancies.This review is organized around key areas that emerged in the process of harmonization: shared background material, evidence grading systems, diagnostic evaluation, blood pressure (BP) classification, role of out-of-office BP monitoring, hypertension treatment including medication choice, cardiovascular risk assessment, knowledge gaps, and importance of transition of care. Since many medical conditions span the age spectrum, this review may also serve as a guide for best-practices in developing disease specific life course guidelines. Now, separate child and adult guidelines are more typical.Shared Background MaterialBoth guidelines succeeded prior guidelines on the same topics, but employed updated evidence evaluation procedures recommended by the National Academy of Medicine that had not been applied to the prior guidelines.3 For the adult guideline, panel members were selected who had no conflicts of interest. For the pediatric guideline, a few panel members had industry relationships. For these, disclosure and adjudication of industry relationships was performed, with inclusion of industry relationships in guideline-related publications. Both guideline panels included patient representatives, had broad representation of expertise (nursing, pharmacology, and primary care), had independent evidence review processes (which were also published), and extensive prepublication review and revision after commentary by experts and critical stakeholders.Both guidelines had shared content areas such as BP measurement methods, secondary causes of hypertension, behavioral interventions, and identification of important comorbidities such as obesity and sleep apnea. Both guidelines relied on the rich literature detailing the natural history of untreated hypertension to provide a strong rationale for prevention of increases in BP in those with a normal BP and those with hypertension. Both guidelines accounted for the intrinsic variability of BP, recommending multiple measurements before confirming a diagnosis of hypertension. Special populations considered included those with diabetes mellitus, chronic kidney disease, and a heart or renal transplant. Disparities were considered, including race/ethnicity, and gender differences. Guideline discrepancies regarding emphasis of special populations reflected the frequency of specific conditions in children versus adults. For example, postoperative coarctation of the aorta was highlighted in the adult guideline whereas both undiagnosed and postoperative coarctation were underscored in the pediatric guideline. Hyperaldosteronism, as a secondary cause of hypertension, was emphasized in the adult guideline but was not featured in the pediatric guideline, whereas many congenital conditions and monogenic disorders associated with hypertension received more emphasis in the pediatric guideline. Ischemic heart disease, heart failure, stroke, and frailty were considered as comorbidities in the adult guideline but not in the pediatric guideline.Evidence Grading SystemsThe structure of the evidence grading systems may have influenced guideline development. The ACC/AHA guideline used the ACC/AHA task force schema whereas the AAP guideline used the AAP schema (Figures 1 and 2). Although both approaches have been informed by the National Academy of Medicine criteria for guideline development, the former was devised strictly for the evaluation of adult cardiovascular recommendations and the latter was devised for the evaluation of recommendations for children across the full range of human medical conditions. Both schemes recognize well-conducted clinical trials as providing the highest level of evidence and afford lower grades for lesser levels of evidence; a 4 tiered system for the AAP and a 3 tiered system for ACC/AHA.Download figureDownload PowerPointFigure 1. American College of Cardiology/American Heart Association guideline task force grading schema. Updated August 2015. Reprinted from Halperin et al4 with permission. Copyright © 2015, American Heart Association, Inc.Download figureDownload PowerPointFigure 2. American Academy of Pediatrics Evidence Grading Schema. Reprinted from Flynn et al1 with permission. Copyright © 2017, American Academy of Pediatrics.Several features of the AAP grading matrix differ from the ACC/AHA algorithm and these discrepancies resulted in grading differences between the guidelines, as discussed below. The AAP grading matrix directly links the level of evidence to the strength of recommendations (strong, moderate, or weak) whereas the ACC/AHA algorithm allows for the provision of a strong recommendation in the presence of expert opinion. Although both grading matrices balance benefit and harm, the ACC/AHA algorithm includes a designation for harm whereas the AAP does not. The AAP algorithm provides a grade X, where a strong recommendation can be made in settings where the performance of clinical trials seems unreasonable or not feasible.Diagnostic EvaluationAlthough the purpose of the diagnostic evaluation in both guidelines is the same—to screen for causes of secondary hypertension and detect subclinical target organ damage—the assessments recommended differ in some respects. Again, these differences are more related to the likelihood of specific comorbidities than to a difference in opinion. (Table 1). Both guidelines recommend blood chemistries, lipid profiles, urinalysis, and evaluation for secondary hypertension based on clinical and laboratory findings. Testing for proteinuria was optional in the adult guideline. The pediatric guideline also recommended a renal ultrasound in those <6 years of age, a hemoglobin A1c and liver function tests in those who are obese, and increased awareness of secondary causes of hypertension in normal weight children. The adult guideline recommended a complete blood count, thyroid stimulating hormone measurement, and ECG, based on the likelihood of finding comorbid conditions or secondary hypertension, whereas the pediatric guideline did not.Table 1. Diagnostic Evaluation for Hypertension1,2PediatricAdultRequired lab workUrinalysis, Blood Chemistry (electrolytes, calcium, and glucose), and Lipid ProfileUrinalysis, blood chemistry (electrolytes, calcium, and glucose), lipid profile plus complete blood count, and thyroid stimulating hormoneOptional lab workHemoglobin A1C, liver function tests if obeseUric Acid, and Urinary albumin/creatinine ratioECGNoYesEchocardiogramAt time of initiating therapyOptionalRenal studiesRenal ultrasound if 140/90 mm Hg in those over 13 years of age), though the pediatric guideline allows for an optional trial of weight reduction in obese children before starting treatment. In the adult guideline, initiation of treatment with 2 medications is recommended in most instances, whereas in the pediatric guideline starting with 1 medication is recommended. In the adult guideline, immediate initiation of treatment for secondary prevention of cardiovascular disease is recommended for those with stage 1 hypertension, a setting unusual in pediatrics. In the pediatric guideline, the treatment goal is below the 90th percentile for children <13 years of age and <130/80 mm Hg for teens ≥13 years of age, whereas it is universally <130/80 mm Hg in the adult guideline.Table 2. Treatment Recommendations from the ACC/AHA and AAP 2017 Guidelines1,2ACC/AHA 1. Use of BP-lowering medications is recommended for secondary prevention of recurrent CVD events in patients with clinical CVD and an average SBP of 130 mm Hg or higher and an average DBP of 80 mm Hg or higher, or for primary prevention in adults with an estimated 10-year ASCVD risk of 10% or higher and an average SBP 130 mm Hg or higher or an average DBP 80 mm Hg or higher. 2. Use of BP-lowering medication is recommended for primary prevention of CVD in adults with no history of CVD and with an estimated 10-year ASCVD risk <10% and an SBP of 140 mm Hg or higher or a DBP of 90 mm Hg or higher.AAP In hypertensive children and adolescents who have failed lifestyle modifications (particularly those who have LV hypertrophy on echocardiography, symptomatic HTN, or stage 2 HTN without a clearly modifiable factor [eg, obesity]), clinicians should initiate pharmacologic treatment with an ACE inhibitor, ARB, long-acting calcium channel blocker, or thiazide diuretic.AAP indicates American Academy of Pediatrics; ACC, American College of Cardiology; ACE, angiotensin converting enzyme inhibitor; AHA, American Heart Associations; ARB, angiotensin receptor blocker; ASCVD, atherosclerotic cardiovascular disease; BP, blood pressure; CVD, cardiovascular disease; DBP, diastolic BP; HTN, hypertension; and SBP, systolic BP.Both guidelines recommend risk assessment before treatment of stage 1 hypertension (130/80 mm Hg< BP 10%. No similar risk calculation exists for children and in fact does not reliably exist for adults under age 40 years. For pediatric risk assessment, the presence of left ventricular hypertrophy on echocardiogram (measured at the time of consideration of medication treatment), secondary hypertension, chronic kidney disease, or diabetes mellitus was a definite indication for treatment of stage 1 hypertension. For the pediatric guideline, persistent BP levels above stage 1 for longer than 6 months, particularly with ABPM confirmation, will generally lead to medication treatment independent of risk though lifestyle management should be continued. In the adult guideline, those with stage 1 hypertension and low 10-year risk will more likely not receive medication.Whereas it is recommended that all children with a diagnosis of hypertension, receive an echocardiogram at the time of initiation of medication treatment, the adult guideline makes no recommendation regarding echocardiography. Instead, the adult guideline discusses settings where obtaining an echocardiogram may be useful for risk assessment including in those at younger age and in adults with comorbidities, similar to those identified for risk stratification in the pediatric guideline. The argument for including echocardiography in assessment is that in observational studies left ventricular hypertrophy is a predictor of cardiovascular outcomes independent of BP and that it is a marker of sustained exposure to elevated BP. However, since no clinical trials show an independent value of echocardiographic measures in predicting outcomes beyond BP lowering, and there are limited studies of its value in risk reclassification, evidence was limited particularly for older individuals.With regard to medication choice, both guidelines recommended initiation of drug therapy from 1 (or 2) of 4 antihypertensive pharmacological classes: angiotensin converting enzyme inhibitors, angiotensin receptor blockers, calcium channel blockers, or thiazide diuretics. Whereas the adult guideline favors calcium channel blockers or thiazides for blacks, the pediatric guideline does not, as clinical trial outcomes with regard to response to these medications based on race is not as strong in pediatric trials as it is in adult trials. Diuretics are less favored as first choice medications in children because of concern regarding lifestyle, particularly interruption in school. In the adult guideline, medication choice is influenced by comorbidities such as ischemic heart disease, heart failure, stroke, atrial fibrillation, and valvular heart disease.Differences in evidence grading systems influenced the final strength of evidence assignment. As mentioned above, the pediatric guideline links strength directly to evidence grade. Because no studies exist linking BP treatment early in life to prevention of cardiovascular outcomes later in life, the evidence grade was B indicating trials or diagnostic studies with minor limitations; consistent findings from multiple observational studies. The recommendation strength was moderate. In contrast, the adult guideline allows for a strong recommendation based on limited data and expert opinion. Given the overwhelming observational evidence regarding BP and cardiovascular risk combined with the consistent benefit seen in higher risk hypertensive populations in clinical trials that included hundreds of thousands of participants, a strong recommendation was given for intervention despite the absence of clinical trial data in adults with stage 1 hypertension who are at lower risk for atherosclerotic cardiovascular disease.Care TransitionTransitions in care are increasingly recognized as areas where treatment adherence is especially unsatisfactory.6 For this reason, the AAP guideline utilizes grade X, with regard to the importance of care transition from pediatric to adult providers (Table 3). This evidence grade recognizes the rare circumstances where performing clinical trials to assess a value, in this case maintaining antihypertensive treatment, do not seem reasonable. This recommendation should not preclude implementation research on the best way to provide effective care transitions from pediatric to internal medicine care.Table 3. Transition of Care RecommendationPediatric Guideline1Adolescents with elevated BP or HTN (whether they are receiving antihypertensive treatment) should typically have their care transitioned to an appropriate adult care provider by 22 y of age (recognizing that there may be individual cases in which this upper age limit is exceeded, particularly in the case of youth with special health care needs). There should be a transfer of information regarding HTN etiology and past manifestations and complications of the patient's HTN.BP indicates blood pressure; and HTN, hypertension.Knowledge GapsThe first evidence gap limiting the ability to harmonize adult and pediatric BP recommendations is the absence of clinical trials in both children and young adults. Ironically, there are more trials in children than studies focusing on those 20 to 40 years of age, thanks to legislation requiring trials in children to achieve pediatric labeling for medications. The incentive of a longer period of exclusivity before medications becoming generic has allowed for conduct of many pediatric BP lowering studies.7 Lack of such data has led to a grade of Incomplete with regard to BP evaluation in childhood by the United States Preventive Services Task Force.8The second evidence gap relates to lack of an age-specific approach across the adult lifespan. Longitudinal data demonstrates that BP in the 120–140 mm Hg systolic range in adolescence and young adulthood predicts both stage 2 hypertension and early events in young adults and middle age.9–11 Although the goals of antihypertensive treatment are similar for those in the 20 to 40 year age group, 40 to 60 year age group, 60 to 80 year age group, and over 80 years group, outcomes may differ across this age spectrum. For younger individuals, prevention of resistant hypertension, target organ injury, and treatment morbidity would have highest importance, whereas likelihood of events, comorbidities, and likelihood of frailty and side effects become more prominent with aging. This consideration points to the need for the conduct of clinical trials that consider prevention of stage 2 hypertension and incorporate subclinical end points in younger cohorts.SummaryEfforts to align the adult ACC/AHA and pediatric AAP BP guidelines were largely successful. Because there are substantial differences in hypertension evaluation in children and adults, the authors currently favor separate guidelines with efforts at alignment for the transition phase. When pediatric hypertension patients transition to internal medicine care, their BP stage will be the same, the target BP for treatment will be the same, lifestyle management will be emphasized for stage 1 hypertension, and medication choices will be similar. Though for stage 1 hypertension, initiation of medication is more likely in childhood, a patient who transitions from pediatric care, should be followed by the adult follow up criteria rather than the adult medication initiation criteria. Evidence gaps preclude alignment regarding long term risk stratification from childhood through age 40 years.DisclosuresNone.FootnotesCorrespondence to Samuel S. Gidding, 1631 Hale Hollow Rd, Bridgewater Corners, VT 05035. Email Samuel.[email protected]comReferences1. 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Gidding S (2021) Diagnosing Hypertension in Childhood, New Considerations, Hypertension, 78:1, (38-39), Online publication date: 1-Jul-2021.Jones D, Whelton P, Allen N, Clark D, Gidding S, Muntner P, Nesbitt S, Mitchell N, Townsend R and Falkner B (2021) Management of Stage 1 Hypertension in Adults With a Low 10-Year Risk for Cardiovascular Disease: Filling a Guidance Gap: A Scientific Statement From the American Heart Association, Hypertension, 77:6, (e58-e67), Online publication date: 1-Jun-2021.Picone D, Schultz M, Armstrong M, Black J, Bos W, Chen C, Cheng H, Cremer A, Dwyer N, Hughes A, Kim H, Lacy P, Laugesen E, Liang F, Ohte N, Okada S, Omboni S, Ott C, Pereira T, Pucci G, Schmieder R, Sinha M, Stouffer G, Takazawa K, Roberts-Thomson P, Wang J, Weber T, Westerhof B, Williams B and Sharman J (2021) Identifying Isolated Systolic Hypertension From Upper-Arm Cuff Blood Pressure Compared With Invasive Measurements, Hypertension, 77:2, (632-639), Online publication date: 1-Feb-2021. 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Falkner B and Jones D (2020) What About Stage 1 Hypertension in Young Adults?, Hypertension, 76:1, (38-39), Online publication date: 1-Jul-2020.Clark D, Hall M and Jones D (2019) Dilemma of Blood Pressure Management in Older and Younger Adults, Hypertension, 75:1, (35-37), Online publication date: 1-Jan-2020. May 2019Vol 73, Issue 5 Advertisement Article InformationMetrics © 2019 American Heart Association, Inc.https://doi.org/10.1161/HYPERTENSIONAHA.119.12653PMID: 30929515 Originally publishedApril 1, 2019 PDF download Advertisement SubjectsCardiovascular DiseaseEpidemiologyPediatricsRisk Factors
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