Milena Archuleta, MSN, MBA, FNP-BC, CPHON University of New … · 2018-04-28 · Prevalence •...
Transcript of Milena Archuleta, MSN, MBA, FNP-BC, CPHON University of New … · 2018-04-28 · Prevalence •...
PEDIATRIC HYPERTENSION CLINICAL PRACTICE GUIDELINES
Milena Archuleta, MSN, MBA, FNP-BC, CPHON University of New Mexico Hospital
Disclosures • None
Hypertension: Why so Important? • Occurs in 3.5% of all pediatric patients • Top 5 chronic diseases in children and adolescents • Missed in up to 75% of pediatric primary care visits • Higher blood pressure in childhood correlates with higher BP in
adulthood • More likely to develop metabolic syndrome • More likely to have accelerated vascular aging and cerebral
vascular accident in adulthood
(Flynn et.al., 2017)
Prevalence • Greater among Hispanic and Non-Hispanic African
American Children
• Higher rates amongst males • Higher rates among adolescents vs. younger children • More prevalent in adolescents who are overweight or obese • Higher rates in children with chronic conditions
• Obesity, sleep disordered breathing, chronic kidney disease, pre-term birth, endocrine disorders, chronic steroid use (i.e malignancies)
(Flynn et. al, 2017)
AAP Guidelines • American Academy of Pediatrics updated clinical practice guidelines
• Replaces the 2004 Guidelines • Updated tables are based on normal weight children • Simplified screening table to identify BPs needing further evaluation • Simplified BP classification in adolescents, ≥ 13 years of age
• Consistent with American Heart Association Guidelines and American College of Cardiology adult guidelines
• Term “pre-hypertension” has been replaced with “elevated blood
pressure”
(Flynn et. al, 2017; Mattoo, 2017)
AAP Guidelines • Limited recommendation on when to perform BP screening
• Expanded role for ambulatory BP monitoring
• Revised recommendations on when to perform echocardiograms
(Flynn et. al, 2017; Mattoo, 2017)
New BP Tables • Based on normal-weight children
• Do not include children and adolescents with overweight and obesity • BMI ≥85th percentile)
• Several millimeters of mercury lower than tables in the Fourth Report
• Include SBP and DBP values arranged by age, sex, and height • Categorized as normal (50th percentile), elevated BP (>90th
percentile), stage 1 HTN (≥95th percentile), and stage 2 HTN (≥95th percentile + 12 mm Hg)
• Heights in centimeters and inches
(Flynn et.al, 2017)
Simplified BP Tables • Designed as a screening tool only to identify children and
adolescents who need further evaluation of their BP • Based on the 90th percentile BP for age and sex for children at
the 5th percentile of height
• Should not be used as single measure to diagnose elevated BP or HTN • Actual cut offs should be used for diagnosis
• For adolescents ≥13 years of age, a threshold of 120/80 mm Hg is used in the simplified table regardless of sex to align with adult guidelines
(Flynn et.al, 2017)
Simplified BP Tables
Staging of Hypertension in the Adolescent
Normal Blood Pressure < 120/80 Elevated Blood Pressure 120/80 to 129/<80 Stage 1 Hypertension 130/80 to 139/89 Stage 2 Hypertension ≥ 140/90
For adolescents ≥ 13 years of age
(Flynn et. al, 2017)
Measurement of Blood Pressure • Measure beginning at 3 years of age
• If they are identified as high risk for HTN you can check prior to < 3 yrs old
• Annual measurement during routine well-child check • At every health visit ONLY if adolescent has obesity, taking
medications known to increase blood pressure, renal disease, diabetes, h/o of aortic arch obstruction or coarctation of the aorta
• If BP is elevated, perform 2 additional readings at the same visit and average them • Auscultation or Oscillometric device
• If repeat readings are still elevated, and if using a oscillometric device, repeat auscultation 2 times and average the readings
(Flynn et.al, 2017)
Primary Hypertension • Older age ≥ 6 years old • Positive family history
• Parent and/or grandparent • Overweight or obese • Typically asymptomatic • Elevated systolic blood pressure
• In children ≥ 6 years old and a positive family history and overweight or obese, adolescents do NOT require extensive work-up for secondary causes of hypertension
(Flynn et.al, 2017; Mattoo, 2017)
Secondary Hypertension • Younger children, pre-puberty • Elevated diastolic blood pressure reading • Typically symptomatic with symptoms related to underlying
cause • Renal disease/ Renovascular disease • Coarctation of the aorta • Endocrine Disorders • Environmental exposures • Neurofibromatosis • Supplements • Medications
• Steroids, decongestants, cold medications, OCPs, Stimulants, anti-depressants, Erythropoietin, Cyclosporin/Tacrolimus, Asthma medication
(Flynn et. al, 2017; Mattoo, 2017)
Goals of Evaluation • Distinguish between primary and secondary hypertension • For children with secondary hypertension, identify and treat
underlying cause
• Identify other comorbid risk factors for coronary vascular disease • Obesity, dyslipidemia, diabetes mellitus
(Mattoo, 2017)
Initial Work-Up • Focused History
• ROS: fatigue, weight loss/weight gain, fevers, flushing, chest pain, palpitations, edema, SOB, snoring, orthopnea
• Family History
• HTN, Early CV disease, CVA, End Stage Renal Disease, DM
• Past Medical History
• Prematurity, neonatal course, OSA, frequent UTIs
Initial Work-Up • Social History
• Tobacco Use, illicit drugs, alcohol, diet, exercise, school/work • Feelings of depression, anxiety, bullying and body image perceptions
• Nutritional History • Salt content, sugars, processed foods
• Medications • Steroids, decongestants, cold medications, OCPs, stimulants, anti-depressants,
Erythropoietin, Cyclosporin/Tacrolimus, asthma medication, supplements
Initial Work-Up • Focused Physical Exam
• Vitals: Repeat BP manually (using appropriate cuff size) • Gen: Moon facies, truncal obesity, buffalo hump • Skin: Hirsutism, butterfly rash, neurofibromas, café au lait spots • HEENT: Retinopathy, crowded oropharynx, enlarged tonsils, thyromegaly • CV: Pulses in all 4 extremities, heart sounds (laying, sitting, standing), edema, carotid bruits • Resp: crackles, rhonci, wheezing • ABD: abdominal mass, pregnancy, abdominal bruits • MSK: Pain with ROM, Joint swelling • PSYCH: Anxiety
Diagnostic Work-Up • Initial Diagnostic Work-Up on All Patients:
• Basic Metabolic Panel • Quick assessment of renal function and electrolyte abnormalities
• Urinalysis • Lipid Panel • Renal U/S
• For any adolescent with an abnormal U/A or renal function
• **Echocardiogram • To be done when pharmacologic measures are considered and should be done
prior to initiating medications
(Flynn, et.al, 2017)
Additional Diagnostic Work-Up • Overweight/obese (BMI > 95th percentile): Hemoglobin A1c, Liver
Enzymes
• Concern for OSA: Sleep Study • Concern for pregnancy: Urine Pregnancy Test • Concern for illicit drug use: UDM
(Flynn et.al, 2017)
Treatment • Goal of treatment is to reduce risk for end-organ damage
• Reduce risk of coronary vascular disease in adulthood
• Reduction of BP < 130/80 in adolescents
• Reduction of BP < 90th percentile in children
Lifestyle Modifications • Counsel regarding weight management and nutrition
• DASH Diet • Limit fast food/processed foods, limit sugar, limit sodium • Increase servings of fruits and vegetables and low fat dairy • Moderate amounts of whole grains, fish, poultry, and nuts
• Regular daily exercise • Goal of 1 hour of physical activity at least 3-5 days per week • Encourage participation in a sport
• Limit screen time and social media to 1-2 hours per day
• Stress Reduction/Meditation
(Flynn et.al, 2017; Mattoo, 2017)
Pharmacologic Management • Stage I hypertension when there is no response to non-pharmacologic
management after 6 months
• Stage 1 hypertension IF symptomatic and/or with end organ disease • Stage II hypertension without a modifiable risk factor • Hypertension associated with chronic kidney disease and diabetes • Initial treatment recommended by the American Academy of Pediatrics:
• ACE Inhibitor • Angiotensin Receptor Blocker • Long-Acting Calcium Channel Blocker • Thiazide diuretics
(Mattoo, 2017)
Pharmacologic Management • Avoid beta-blockers and potassium sparing diuretics as initial treatment
• If not controlled with single agent, may consider adding a second agent of different class
• Starting doses should be the lowest known dose
• Medication can be increased every 2-4 weeks until BP is controlled
• Should be seen in clinic every 4-6 weeks until BP is well controlled • Once blood pressure is well controlled, may extend follow-up to every 3-6
months • Continue counseling on lifestyle modifications
(Flynn et. al, 2017)
ACE Inhibitors • Mechanism of Action: Prevents conversion of Angiotensin I to
Angiotensin II, resulting in increased renin activity and reduction in aldosterone secretion
• Contraindicated in pregnancy
• Discontinue immediately if pregnancy is suspected. Can cause injury or death to the fetus
• Side Effects
• Common: Cough, headache, dizziness • Severe: Hyperkalemia, AKI, angioedema
• Monitor BUN/Cr and baseline electrolytes prior to starting • Periodically check throughout treatment
(Up to Date, 2017)
ACE Inhibitors • Lisinopril
• Initial Dose: 0.07-0.1 mg/kg/dose once daily • Max Initial Dose = 5mg/DAY
• May increase in 1-2 week intervals • Max daily dose= 40mg/DAY
• Fosinopril • < 50 kg: 0.1mg/kg/dose once daily • > 50 kg: 5-10mg once daily • Max daily dose = 40mg/DAY
• Other: Benazapril, Captopril, Quinapril
• Typically very well tolerated
• When to Consider: Typically used as first line medication; diabetes, Proteinuria, Chronic Kidney Disease
(Up to Date, 2017)
Angiotensin Receptor Blockers • Mechanism of Action: Blocks the vasoconstriction and
aldosterone secreting effects of angiotensin II • Contraindicated in pregnancy
• Discontinue immediately if pregnancy is suspected. Can cause injury or death to the fetus
• Side Effects
• Common: headache, dizziness • Severe: Hyperkalemia, AKI, angioedema
• Monitor BUN/Cr and baseline electrolytes prior to starting. • Periodically check throughout treatment
(Up to Date, 2017)
Angiotensin Receptor Blockers • Losartan
• 0.7 mg – 1.4mg/kg/dose once daily • Max Dose = 100 mg/DAY
• Valsartan • 1.3mg – 2.7mg/kg/dose once daily
• Max Dose = 160mg/DAY
• Other: Candesartan, Olmesartan, Irbesartan (not indicated in children)
• Typically well tolerated • When to Consider: Could not tolerate ACE due to cough, Diabetes,
Proteinuria, Chronic Kidney Disease
Calcium Channel Blockers • Mechanism of Action: Inhibits Calcium from entering the slow
channels of vascular smooth muscle and myocardium during depolarization, producing relaxation of coronary vascular smooth muscle and coronary vasodilation
• Contraindication: Hypersensitivity to calcium channel blockers; Sick Sinus Syndrome
• Side Effects
• Common: flushing, peripheral edema, dizziness • Severe: angioedema
• Monitor heart rate and baseline liver enzymes (Up to Date, 2017)
Calcium Channel Blockers • Amlodipine
• Initial dose: 2.5mg-5mg once daily • Max Dose= 10mg/DAY
• Isradapine • Initial dose: 0.15 mg- 0.2mg/kg/day divided 3-4 times daily
• Max dose = 20 mg/day • Most adult patients do not show an improvement with doses > 10mg/day
• Other: Felodipine, Nifedepine
• When to consider: Diminished renal function, hyperkalemia, and sexually active females who are unable to take or non- adherent to contraception
(Up to Date, 2017)
Thiazide Diuretics • Mechanism of Action: Inhibits sodium reabsorption in the distal
tubules causing increased excretion of sodium and water as well as potassium
• Contraindications: Anuria, hypersensitivity to thiazide diuretics or
sulfonamide derived drugs • Side Effects
• Common: Dizziness, hypokalemia • Severe: Cardiac dysrhythmia, hyperglycemia, jaundice, pancreatitis
• Monitor BUN/Cr, glucose, electrolytes. Obtain baseline basic metabolic panel and repeat at least 4 weeks after starting and continue to monitor periodically throughout treatment
(Up to Date, 2017)
Thiazide Diuretics • Hydrochlorothiazide
• 1mg-2mg/kg/day in 1-2 divided doses • Max dose = 100mg/DAY
• Chlorthalidone • 0.3mg/kg/dose once daily • Max dose = 50 mg/DAY
• When to Consider: Often preferred second agent
(Up to Date, 2017)
Beta-Blockers • Mechanism of Action: Selective inhibitor of beta 1 adrenergic
receptors • Contraindications: asthma, heart block • Side-Effects
• Common: Bradycardia, dizziness, fatigue, headache, blurred vision • Severe: Bronchospasm, dyspnea, heart block
• Monitor heart rate throughout treatment
(Up to Date, 2017)
Beta Blockers • Metoprolol
• 0.5mg- 1mg/kg/dose divided BID • Max Initial Dose = 25mg/dose • Max Daily Dose = 200 mg/DAY
• Atenolol
• 0.5mg- 1mg/kg/dose divided BID or once daily • Max Daily Dose = 100 mg/DAY
• Other: Propranolol, Carvedilol
• When to Consider: Adolescents of childbearing potential; children not responsive to ACE, ARB, Thiazides, or Calcium Channel Blockers; Typically 3rd line agent
(Up to Date, 2017)
Elevated Blood Pressure
• Children (1-13): • Elevated BP: ≥90th percentile
• Adolescents (≥13 years of age): • 120/80 to 129/ <80
(Flynn et. al, 2017)
Elevated Blood Pressure • Lifestyle modifications • Weight management • Initial labs: Basic Metabolic Panel, Urinalysis, and Lipid Panel • Follow-up in 6 months
• Repeat BP • Lifestyle modifications, weight management counseling • F/U again in 6 months • If BP still elevated after 12 months consider:
• Ambulatory blood pressure monitoring • Full Diagnostic work-up • Consider referral to subspecialty
• If BP normalizes at any point. Return to annual screening
Stage 1 Hypertension • Children (1-13):
• ≥95th percentile
• Adolescents (≥13 years of age): • 130/80 to 139/89
Stage 1 Hypertension • Lifestyle modifications • Weight management • Initial Labs: Initial labs: Basic Metabolic Panel, Urinalysis, and Lipid
Panel • Repeat BP in 1-2 weeks, if BP still at Stage 1, follow-up in 3 months • 3 Month Follow-Up
• Repeat blood pressure • Lifestyle and weight management counseling • If still elevated after 3 months consider
• Ambulatory blood pressure monitoring • Diagnostic evaluation • Initiate treatment • Consider referral to subspecialty
(Flynn et. al, 2017)
Stage 2 Hypertension • Children (1-13):
• ≥95th percentile + 12 mm Hg
• Adolescents (≥13 years of age): • ≥ 140/90
Stage 2 Hypertension • Lifestyle modifications and weight management counseling • Initial Labs: Basic Metabolic Panel, Urinalysis, Lipid Panel
• If asymptomatic, repeat BP in 1 week • Alternatively may refer to specialty within 1 week
• If BP remains elevated: • Ambulatory BP monitoring • Echocardiogram • Initiate pharmacologic treatment • Refer to subspecialty
• If symptomatic or BP > 180/120 refer to immediate care
(Flynn et.al, 2017)
Hypertensive Emergency
• Symptoms consistent with hypertensive emergency • Severe headache, seizures, mental status changes, vomiting, focal
neurologic complaints, visual disturbances, chest pain, SOB, palpitations
• Require immediate pharmacologic management and typically hospitalization for evaluation of ongoing care
(Mattoo, 2017)
Sports Participation • Elevated Blood Pressure (120/80 to 129/<80)
• May participate in sports without restriction
• Stage 1 Hypertension (130/80 to 139/89) • May participate in sports without restriction if there is no evidence of end
organ damage • Repeat blood pressure 1-2 weeks after starting sport • Stage 2 Hypertension (≥ 140/90) • Restricted from high static sports • Once treated and normotensive, may participate in sports without restriction
• No data linking the presence of HTN to sudden death related to sports participation
(Mattoo, 2017)
Prevention • Lifestyle modifications • Dietary Intervention • Exercise
AJ • 15 year old Hispanic male here for routine sports physical • Past Medical Hx:
• Born at term, vaginal delivery, no complications • Broken right wrist after a fall
• Family Medical Hx:
• Maternal Grandmother: Controlled Type 2 DM, HTN, Hypothyroid • Mother: GERD • Father: Controlled Type 2 DM, HTN • Sister: Healthy
• Social History:
• Exercise: Football games/practice daily for at least 60 min; Weight training 3 days per week • Diet: Protein shakes prior to each practice, 2 Dr. Pepper’s per day, eats fast food approx 4 d/wk, 3
Bottles of Gatorade per day • Tobacco/Drugs/ETOH: Denies use, however does have secondary exposure. Father does smoke • Works 20 hours per week at local grocery store
• Medications: NONE
AJ • ROS: Tired during the day, headaches after football practice • Vital Signs:
• T: 36.7; HR: 85; RR: 18; O2: 98% RA • Wt: 160 lbs (90%); HT: 5’8” (50%); BMI: 24 (90%) • BP: 139/88 (automated cuff); 135/80 (1st manual repeat) ; 138/85 (2nd manual repeat) • Average BP reading: 136/84
• Physical Exam • Unremarkable
• Labs: • Urinalysis: + for trace protein
• Review of chart shows BP of 130/80 and 132/82 on 2 separate visits over the last year
AJ
• Diagnosis: • Stage 1 Hypertension • Proteinuria • Overweight
AJ • Stage 1 Hypertension
• BMP, urinalysis, lipid panel • Lifestyle modifications, weight management counseling • Ok to participate in football • RTC in 3 months to follow-up BP and lifestyle modifications
• Proteinuria • Renal U/S
• Overweight • Lifestyle modifications, weight management counseling
AJ, 3 month Follow-Up • Social: Stopped part-time job to focus on sports and school, stopped Dr. Pepper and now
only drinking 1 bottle of Gatorade per day, mother packing lunch and cooking dinner daily. Father stopped smoking
• T: 36.7; HR: 85; RR: 18; O2: 98% RA; Wt:160 lbs (90%); HT: 5’8” (50%); BMI: 24
(90%) • BP: 130/80, repeat auscultated measure: 132/85 • Physical Exam
• Unremarkable
• Labs: • BMP-Normal • Lipid Panel- Normal
• Renal U/S: • Unremarkable
AJ, 3 month Follow-Up • Stage 1 Hypertension
• No response with lifestyle modifications • Continue weight management and lifestyle modifications • Ambulatory blood pressure monitoring • Diagnostic evaluation
• Considering Treatment: Echocardiogram
• Consider referral to subspecialty
• F/U in 1 month to review echocardiogram results
AJ, FU Echo Results • Echocardiogram is normal
• Review of Ambulatory BP shows an average reading of 135/80
• After a total of 6 months and continued stage 1 hypertension, you decide to initiate medications
What Medication to Choose? • Lisinopril
• Metoprolol
• Losartan
• Hydrochlorothiazide
What Did I Choose?
• Lisinopril • 5mg PO q day
What Medication to Choose? • Lisinopril
• Typically well tolerated • Low side-effect profile
• Metoprolol • Not generally used as first line medication • Would not choose in active teen, due to side-effects particularly fatigue
• Losartan • Also well tolerated • Would like to have as a second choice if ACE is not tolerated due to cough
• Hydrochlorothiazide
• Often preferred as a second agent • Would try to avoid in active teen due to side effects
References • Flynn, J., Kaelber, D., Baker-Smith, C., Blowey, D. Carroll, A., Daniels, S., De
Ferranti, S., …Uribina, E. (2017). Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. American Academy of Pediatrics. Retrieved from http://pediatrics.aappublications.org/content/140/3/e20171904
• Mattoo, T., Stapleton, F., & Kim, M. (2017). Nonemergent Treatment of Hypertension in Children and Adolescents. Up to Date. Retrieved from https://www.uptodate.com/contents/nonemergent-treatment-of-hypertension-in-children-and-adolescents?source=search_result&search=Nonemergent%20managment%20hypertension%20adolescents&selectedTitle=1~150
• Mattoo, T., Stapleton, F., & Kim, M. (2017). Evaluation and Management of Hypertension in Children and Adolescents. https://www.uptodate.com/contents/evaluation-of-hypertension-in-children-and-adolescents?source=search_result&search=adolescent%20hypertension&selectedTitle=1~150
References • Up to Date (2017). Pediatric Drug Information: Amlodipine. Retrieved from
https://www.uptodate.com/contents/amlodipine-pediatric-drug-information?source=search_result&search=Amlodipine&selectedTitle=2~121
• Up to Date (2017). Pediatric Drug Information: Hydrochlorothiazide. Retrieved from https://www.uptodate.com/contents/hydrochlorothiazide-pediatric-drug-information?source=search_result&search=hydrochlorothiazide&selectedTitle=2~150
• Up to Date (2017). Pediatric Drug Information: Lisinopril. Retrieved from https://www.uptodate.com/contents/lisinopril-pediatric-drug-information?source=search_result&search=Lisinopril&selectedTitle=2~83
• Up to Date (2017). Pediatric Drug Information: Metoprolol. Retrieved from https://www.uptodate.com/contents/metoprolol-pediatric-drug-information?source=search_result&search=metoprolol&selectedTitle=2~150