2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents

TLDR: The recommendations of the present document represent the best clinical wisdom upon which physicians, nurses and families should base their decisions and should encourage public policy makers to develop a global effort to improve identification and treatment of high blood pressure among children and adolescents.

Abstract: Increasing prevalence of hypertension (HTN) in children and adolescents has become a significant public health issue driving a considerable amount of research. Aspects discussed in this document include advances in the definition of HTN in 16 year or older, clinical significance of isolated systolic HTN in youth, the importance of out of office and central blood pressure measurement, new risk factors for HTN, methods to assess vascular phenotypes, clustering of cardiovascular risk factors and treatment strategies among others. The recommendations of the present document synthesize a considerable amount of scientific data and clinical experience and represent the best clinical wisdom upon which physicians, nurses and families should base their decisions. In addition, as they call attention to the burden of HTN in children and adolescents, and its contribution to the current epidemic of cardiovascular disease, these guidelines should encourage public policy makers to develop a global effort to improve identification and treatment of high blood pressure among children and adolescents.

Figures

Table 4.4.1. Physical examination

Table 4.5.1. Laboratory investigation and imaging studies

Table 8.2.2. Clinical conditions for which specific antihypertensive drug classes are recommended or contraindicated

Table 8.2.2. Clinical conditions for which specific antihypertensive drug classes are recommended or contraindicated

Table 3.1.1. European studies of hypertension prevalence in children and adolescents

FIGURE 2.1.1. Flow-chart for the diagnosis of hypertension based on Percentile distribution of age, sex and height. (< 16 y) and on defined threshold (≥16y) P, percentile.

Full text

Lurbe, E. et al. (2016) 2016 European Society of Hypertension guidelines for the
management of high blood pressure in children and adolescents. Journal of
Hypertension, 34(10), pp. 1887-1920.
There may be differences between this version and the published version. You are
advised to consult the publisher’s version if you wish to cite from it.
http://eprints.gla.ac.uk/121757/
Deposited on: 14 September 2016
Enlighten – Research publications by members of the University of Glasgow
http://eprints.gla.ac.uk

Journal of Hypertension
2016 EUROPEAN SOCIETY OF HYPERTENSION (ESH) GUIDELINES FOR THE
MANAGEMENT OF HIGH BLOOD PRESSURE IN CHILDREN AND ADOLESCENTS
Manuscript Number:
Full Title: 2016 EUROPEAN SOCIETY OF HYPERTENSION (ESH) GUIDELINES FOR THE
MANAGEMENT OF HIGH BLOOD PRESSURE IN CHILDREN AND ADOLESCENTS
Article Type: Consensus document
Keywords: adolescents; children; European; management of high blood pressure;
recommendations; society of hypertension; out of office BP; central BP.
Corresponding Author: Empar Lurbe, Prof. MD. PhD
Consorcio Hospital General. University of Valencia and CIBER Fisiopatología
Obesidad y Nutrición (CB06/03), Instituto de Salud Carlos III
Valencia, SPAIN
Corresponding Author Secondary
Information:
Corresponding Author's Institution: Consorcio Hospital General. University of Valencia and CIBER Fisiopatología
Obesidad y Nutrición (CB06/03), Instituto de Salud Carlos III
Corresponding Author's Secondary
Institution:
First Author: Empar Lurbe, Prof. MD. PhD
First Author Secondary Information:
Order of Authors: Empar Lurbe, Prof. MD. PhD
Enrico Agabiti-Rosei
J Kennedy Cruickshank
Anna Dominiczak
Serap Erdine
Asle Hirth
Cecilia Invitti
Mieszyslaw Litwin
Giuseppe Mancia
Wolfgang Rascher
Josep Redon
Franz Schaefer
Tomas Seemann
Manish Sinha
Stella Stabouli
Nicholas J Webb
Elke Wühl
Alberto Zanchetti
Order of Authors Secondary Information:
Abstract: Increasing prevalence of hypertension in children and adolescents has become a
significant public health issue driving a considerable amount of research. Aspects
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discussed in this document include advances in the definition of hypertension in 16
year or older, clinical significance of isolated systolic hypertension in youth, the
importance of out of office and central blood pressure measurement, new risk factors
for hypertension, methods to assess vascular phenotypes, clustering of cardiovascular
risk factors, and treatment strategies among others. The recommendations of the
present document synthesize a considerable amount of scientific data and clinical
experience, and represent the best clinical wisdom upon which physicians, nurses and
families should base their decisions. In addition, because they call attention to the
burden of hypertension in children and adolescents, and its contribution to the current
epidemic of cardiovascular disease, these guidelines should encourage public policy
makers to develop a global effort to improve identification and treatment of high blood
pressure among children and adolescents.
Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation

Abbreviation
ABPM
ambulatory BP measurement
ACE
angiotensin converting enzyme
ACEi
angiotensin converting enzyme inhibitor
ACTH
adeenocorticotropic hormone
ARB
angiotensin receptor blocker
BP
blood pressure
cIMT
carotid intima-media thickness
CKD
chronic kidney disease
CoA
coarctation of aorta
CPAP
continuous positive airway pressure
cPP
central pulse pressure
CS
Cushing syndrome
cSPB
central or aortic systolic blood pressure
CT
computed tomography
CV
cardiovascular
DBP
diastolic blood pressure
DIH
drug-induced hypertension
DM1
type 1 diabetes
DM2
type 2 diabetes
EM
ethnic minorities
ENaC
epithelial sodium channel
ESC
European Society of Cardiology
ESCAPE
Effect of Strict Blood Pressure Control and ACE Inhibitionon Progression of
Chronic Renal Failure in Pediatric Patients
ESH
European Society of Hypertension
ESRD
end stage renal disease
EU
European Union
FH1,2,3
familial hyperaldosteronism type 1,2,3
GFR
glomerular filtration rate
HTN
hypertension
HTNR
hypertensive retinopathy
ISH
isolated systolic hypertension
LDL-C
low density lipoprotein cholesterol
LV
left ventricle
LVH
left ventricular hypertrophy
LVM
left ventricular mass
LVMI
left ventricular mass index
MR
mineralocorticoid receptor
MRI
magnetic resonance image
OSA
obstructive sleep apnea
PRES
posterior reversible encephalopathy syndrome
PUMA
Paediatric Use Marketing Authorisation
PWV
pulse wave velocity
RAS
renin-angiotensin system
SBP
systolic blood pressure
SNPs
single nucleotide polymorphisim
SPRINT
Systolic Blood Pressure Intervention Trial
TOD
target organ damage
UAE
Urinary albumin excretion
VEGF
vascular endothelial growth factor
Abbreviations definition list

Frequently asked questions

Q1. What is the mainstay of antihypertensive management in children and adolescents?

Although non-pharmacological options should be considered, drug treatment remains the mainstay of antihypertensive management in all stages of CKD. 

Q2. What is the first line of therapy for a child with a BP problem?

First-line therapy includes salt restriction and agents that target the renin-angiotensin-aldosterone-system combined with beta-blockers in low doses if necessary to achieve BP control. 

Q3. What is the likely scenario for the use of biomarkers?

The most likely scenario is that the emerging disruptive technologies such as genomics, proteomics and metabolomics would change the way the authors use biomarkers. 

Q4. What are the earliest detectable findings in children with CKD?

Emerging data suggest that functional changes in large vessels are the earliest detectable findings in children, for example in those with familial hypercholestrolaemia and CKD (128,129). 

Q5. What is the appropriate first line agent for a child with a DM?

For instance, in a child with HTN associated with DM and microalbuminuria, or with CKD and proteinuria, an ACE inhibitor or ARB is the most appropriate first line agent because of their antiproteinuric effect. 

Q6. How many antihypertensive drugs were required to achieve the lower BP target?

On average 1.9 antihypertensive drugs (including the ACE inhibitor ramipril provided at a fixed dose) were required to achieve the lower BP target. 

Q7. How many children require more than one drug to achieve a sufficiently low BP target?

In three-quarters of hypertensive children with CKD stage 2-4, BP control can be achieved by antihypertensive monotherapy, but at least 50% of children require more than one drug to achieve a sufficiently low BP target. 

Q8. What should be the first step in detecting a cause of secondary HTN?

Since the most common form of secondary HTN in children and adolescents are diseases of the renal parenchyma, screening to detect an underlying cause of HTN should start with specific tests to detect renal abnormalities. 

Q9. What is the main reason for choosing a drug that can be administered once daily?

It is logical to choose an agent which can be administered once-daily because of the benefits that this provides in terms of simplicity of administration, allowing tablet-taking to be incorporated into the patient’s daily routine (e.g. bedtime, tooth brushing etc.) and avoiding having to take drugs during school hours. 

Q10. What is the benefit of starting with drugs blocking the renin angiotensin system?

An additional benefit of starting with drugs blocking the renin angiotensin system (either ACE inhibitor or ARB), is promised by their ability to reduce urinary albumin excretion and delay the onset of nephropathy, although the advantage in long-term protection has not been established (225).39 

Q11. Why did the US Preventive Services Task Force decide to use the normative data?

Because of the persisting lack of European reference values that incorporate age, sex and height, throughout the entire pediatric age range, the authors confirm the decision of the 2009 ESH Guidelines (1), to use the normative data on auscultatory clinic measurements provided by the US Task Force (7), providing BP percentiles for each sex, ages from 1-17 years and for seven height percentile categories. 

Q12. What is the definition of a cut-off for defining BP in children and adolescents?

In the absence of prospective long-term studies on the impact of different BP levels on intermediate or major CV and renal end-points in children, the 95th percentile is considered as cut-off for defining HTN in children and adolescents. 

Q13. What is the current European and US guidelines for a BP target in children with CK?

The current European (92) and US guidelines (184) recommend a target BP below 140/90 mmHg in adults with CKD due to insufficient published evidence for an additional benefit of an even lower target concerning mortality or CV or cerebrovascular morbidity. 

Q14. What is the significance of monitoring organ damage in children and adolescents with elevated BP?

Monitoring organ damage in children and adolescents with elevated BP is even moreimportant as the CV/renal sequelae of childhood-onset HTN may not become clinically relevant before adulthood. 

Q15. What is the way to determine what dose of physical activity is for children?

Although children less than 5 years old benefit from being active, more research is needed to determine what dose of physical activity provides the greatest health benefits. 

Q16. What are the benefits of improved imaging methods?

Improved imaging methods (high definition ultrasound and echotracking) have enhanced ‘reference’ values for cIMT and arterial distensibility in healthy children aged 3-18 years (113,114).