Good Morning Everyone!

Monday, July 25th, 2011

Hypertension in Childhood

Diagnostic Evaluation COST

Confirm the diagnosis Organize a diagnostic approach Determine the Severity of the HTN Treat the HTN effectively

Confirm the Diagnosis

Suspect when the BP reading is high for the height, age, and sex of the child

Confirmed when a high reading is obtained at three or more separate office visits about 1 week apart

Confirm the Diagnosis

Ensure proper BP cuff size Bladder should encircle the arm by at least 80%

*

Organize a Diagnostic Approach

MONSTER Medications Obesity Neonatal history Symptoms or signs Trends in the family Endocrine or renal

**Remember, amphetamines, corticosteroids, contraceptives, cyclosporine, OTC allergy and cold medicine and licorice can cause HTN

•BMI > 95%•3 to 5 times more likely to have hypertension•Can have obstructive sleep apnea syndrome (OSAS)• Causes significantly higher diastolic BPs

Organize a Diagnostic Approach

Evaluation is guided by history and physical Biochemical and imaging studies are used to

address three primary organ systems: endocrine, renal, and cardiovascular

Suggested Eval for Children with HTN

Uric Acid

High uric acid is associated with high BP readings in childhood that may persist into adulthood (Bogalusa Heart Study)

Strong relationship between uric acid and essential HTN (found in 89%, but only 30% with secondary HTN, none with white-coat HTN)

Determine the Severity

Combo of magnitude of BP elevation and presence of LVH on echo are proof of sustained HTN Cardiac hypertrophy is major indication for

therapy Finding of LVH suggests risk for future CV

disease

Treatment*

Nonpharmacologic treatment Lifestyle modifications or environmental

changes must be implemented or at least attempted!

Reducing sodium intake Physical activity

If significant essential or severe HTN, avoid weight lifting, body building, and strength training

Restriction based on the possibility of catastrophic event

Treatment

Goal is normalization or near-normalization of BP based on age, sex, and height using a drug regimen that causes minimal adverse effects

Consider starting with one drug and maximizing dose before adding a second agent

Treatment

First-line ACE inhibitors (ex: Captopril, Enalpril)

SE = renal impairment, hyperkalemia, neutropenia, anemia, dry cough, angioedema

Angiotensin receptor blockers SE = renal impairment, hyperkalemia, neutropenia,

anemia Calcium channel blockers (ex: Nifedipine,

Isradipine) SE = peripheral edema, dizziness, nausea, headache,

flushing, weakness

Treatment

Second-line therapy Beta-blockers Central alpha agonists (Clonidine) Vasodilators (Hydralazine, Minoxidil) Diuretics

QUIZ Answers

1. E. Schedule 2 subsequent visits to measure BP

2. A. Echocardiography

3. B. Hyperkalemia

4. D. Perform renal ultrasonography

Have a great day!

Noon conference is Inpatient ID with Dr. Begue