Arterial hypertension in children

Abstract

The purpose of this brief report is to emphasize the importance of blood pressure measurement, a method available at all levels of healthcare to detect and reduce cardiovascular risks in the first years of life. Primary hypertension is one of the most common chronic diseases in adolescence (1). In the pediatric population, arterial hypertension may also reflect chronic diseases such as renal and endocrine disorders or congenital heart defects, including stenosis and coarctation of the aorta (2). Arterial hypertension is defined as systolic and/or diastolic blood pressure values ≥ the 95th percentile for age, sex and height on at least three separate examinations. It is important to note that every healthy child older than three years of age should have their blood pressure measured once a year. The most important prerequisites for a proper measurement are a cuff of the correct size and standardized measurement conditions. 

The importance of this is shown by the fact that a cuff that is too wide can lead to falsely low readings, while a cuff that is too tight can lead to falsely high readings. Children at high risk of developing high blood pressure (e.g. children with kidney disease, premature birth or congenital heart defects) should have their blood pressure recorded before the age of three and measured at every visit (3).

In 2019, practical guidelines for the diagnosis and treatment of hypertension in children and adolescents were published as a supplement to the journal Medix. (4) Home blood pressure monitoring is recommended for children receiving antihypertensive therapy who are at high risk for hypertension or who are suspected of having white coat hypertension. To confirm the diagnosis, assess the severity of hypertension, evaluate the effectiveness of treatment, diagnose resistant hypertension and monitor hypertension in children with chronic conditions, 24-hour ambulatory blood pressure monitoring (ABPM) performed (4).

Primary hypertension has a multifactorial origin. Risk factors include obesity, high salt intake, stress and other lifestyle factors. It is typically grade I hypertension in children over the age of eight with a positive family history (1). Secondary hypertension should be suspected in younger children, especially those with severely elevated blood pressure that is difficult to regulate despite treatment measures, or in children who already have complications at the time of diagnosis. Possible causes of secondary hypertension are diseases of the renal parenchyma, endocrine, cardiovascular, pulmonary or neurological disorders or renovascular hypertension (2).

As with other chronic diseases, the diagnostic process begins with a detailed history, physical examination and laboratory testing, the extent of which depends on whether primary or secondary hypertension is suspected. In addition to standard laboratory and imaging studies, including measurement of enzymes and proteins specific to each organ system, it is necessary to assess target organ damage, including proteinuria, left ventricular hypertrophy, carotid artery intima-media thickness, and an ophthalmologic examination to confirm or rule out hypertensive retinopathy. Specific laboratory tests to rule out secondary hypertension include plasma renin, aldosterone, cortisol, serum and urine catecholamines, and thyroid hormone levels (4).

Treatment depends on the severity of hypertension, comorbidities, duration of disease, presence of target organ damage, risk factors and type of hypertension. Lifestyle modifications, including dietary changes, increased physical activity and elimination of risk factors such as smoking, form the basis of non-pharmacological treatment. Pharmacologic treatment is initiated when symptomatic hypertension, grade II hypertension, target organ damage, secondary hypertension, diabetes, or lack of blood pressure control after one year of lifestyle measures are present (Figure 1).

Approved antihypertensive medications for children in Croatia include amlodipine, enalapril, ramipril, lisinopril, valsartan, losartan, candesartan, propranolol and metoprolol (4).

Since the atherosclerotic process begins in early childhood, prevention and elimination of risk factors are crucial as long as the vascular changes are still reversible.