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Thera X > 14 Pediatric Hypertension Steinberg > Flashcards

14 Pediatric Hypertension Steinberg Flashcards

1
Q

Among racial/ethnic groups in children, who had the highest prevalence of HTN?

A

Blacks and Asians

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2
Q

When should BP measurements for Children be taken?

A

Children 3+ years old who are seen in a medical setting. Elevated BP must be confirmed on repeated visits before characterizing a child as having HTN

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3
Q

What is the preferred method of BP measurement in children?

A

Auscultation. Correct measurement requires a cuff that is appropriate to the size of the child’s upper arm

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4
Q

What happens with BP measurements with Oscillometric devices?

A

Measurements that exceed the 90th percentile should be repeated by auscultation

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5
Q

How are BP cuff bladders calculated?

A

So that the targets arm would still allow the bladder to encircle the arm by > 80%

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6
Q

What is BP measurement accuracy like in regards to location and training?

A

14% of children were misclassified as hypertensive or normotensive and others were misdiagnosed as to the stage of HTN by the Vital Signs Station (VSS) techniques. Different locations/personnel measure BP differently

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7
Q

What is Ambulatory Blood Pressure Monitoring like?

A

Measure blood pressure Q15 mins while awake; Q30 mins while asleep. White-coat HTN. Target-organ injury risk. Apparent drug resistance. Drug-induced Hypotension

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8
Q

What are some conditions under which children < 3 years old should have BP measured?

A

History of prematurity, very low birth weight, or other neonatal complication requiring intensive care. Congenital heart disease. Recurrent UTI, hematuria, proteinuria. Known renal disease or urologic malformations. Family history of congenital renal disease. Solid-organ transplant. Malignancy or bone marrow transplant. Treatment with drugs known to raise BP. Other systemic illness associated with HTN. Evidence of elevated intracranial pressure

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9
Q

What is considered “Normal” pediatric BP?

A

BP < 90th percentile for height and sex

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10
Q

What is considered “Pre-HTN” pediatric BP?

A

Average SBP or DBP levels that are > the 90th percentile, but < the 95th percentile; adolescents w/ BP levels > 120/80 mmHg should be considered pre-HTN

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11
Q

What is considered “HTN” pediatric BP?

A

Average SBP and/or DBP that is > the 95th percentile for sex, age, and height on 3 or more occasions

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12
Q

What is considered “Whitecoat HTN”?

A

A patient with BP levels > 95th percentile in a physician’s office or clinic, who is normotensive outside a clinical setting. Ambulatory BP monitoring is usually required to make this diagnosis

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13
Q

What should be done for a BP > 90th percentile?

A

Measurement should be repeated twice (3 measurements in total) at the same office visit

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14
Q

What should be done with a BP > 95th percentile?

A

HTN should be staged. Stage 1: > 95th percentile up to 99th percentile + 5mmHg. Stage 2: > 99th percentile + 5mmHg

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15
Q

What is the primary cause of HTN in Adolescents?

A

Primary/Essential (this includes HTN d/t obesity)

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16
Q

What are the primary causes of HTN in School-Aged children?

A

Secondary (primarily Renal Parenchymal Disease)

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17
Q

What are the primary causes of HTN in infants?

A

Secondary (primarily Aortic Coarctation > Renovascular > Renal parenchymal disease). Primary/Essential causes are non-existent in infants

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18
Q

What are the general characteristics of Coarctation of the Aorta?

A

Important, treatable cause of secondary HTN. Most often detected via a murmur or HTN found on routine exame

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19
Q

What is considered evidence of Coarctation of the Aorta?

A

Delayed or absent femoral pulses and an arm/leg SBP difference of > 20mmHg in favor of the arms may be considered as evidence. Demonstrated on two-dimensional Doppler echocardiogram

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20
Q

What does a cardiac catheterization reveal for Coarctation of the Aorta?

A

Significant systolic pressure gradient (> 20mmHg) across the coarctation and angiography demonstrates the degree and type of aortic narrowing

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21
Q

What are the primary mechanisms of obesity-related HTN?

A

Sodium retention. Increased SNS (sympathetic nervous system) activity. Increased circulating renin-angiotensin. Increased adipose renin-angiotensin. Impaired vascular endothelial function. Other vascular mechanisms

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22
Q

What are some common medications that can raise BP in children?

A

Steroids. NSAIDs. Heavy metals. Decongestants. Nicotine, caffeine, dextroamphetamine (Adderall). Rapid withdrawal of Clonidine, B-blockers (rebound HTN)

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23
Q

What are the presenting signs of HTN in Neonates?

A

Failure to thrive. Seizure. Irritability or lethargy. Respiratory distress. Congestive heart failure

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24
Q

What are the presenting signs of HTN in Children (additional Sx)?

A

HA. Fatigue. Blurred vision. Epistaxis. Bells palsy

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25
Q

What should the evaluation of Hypertensive children include?

A

Assessment for additional risk factors and for secondary HTN. Comprehensive medical history should be obtained; history of drug and substance use should be included. Because of an association of sleep apnea with overweight and high BP, a sleep history should be obtained; family Hx also important

26
Q

Why would Plasma Renin be evaluated?

A

Identify low renin, suggesting mineralcorticoid-related diseases

27
Q

What is Uric Acid and Pediatric HTN like?

A

Increased serum uric acid is associated with increased risk for future HTN in several large trials. Uric acid causes HTN through: The activation of the renin-angiotensin system, Downregulation of nitric oxide, Induction of endothelial dysfunction and vascular smooth muscle proliferation

28
Q

What did treatment of Allopurinol (for uric acid) show?

A

200mg BID in adolescents with new-onset HTN –> SBP -7, DBP -5. 67% achieved normal BPs

29
Q

What are the suggested cut-offs for uric acid values in boys and girls?

A

Boys: 6.5mg/dl. Girls: 4.9mg/dl

30
Q

What is the most prominent evidence of target-organ damage in children?

A

Left ventricular hypertrophy (LVH). Pediatric patients with established HTN should have echocardiographic assessment of left ventricular mass at diagnosis and periodically thereafter. The presence of LVH is an indication to initiate/intensify antihypertensive therapy

31
Q

What do additional childhood examinations showing increased SBP show?

A

Increasing relative risk of adult HTN and metabolic syndrome

32
Q

How often should pediatric BP be measured in normal patients?

A

Recheck at next scheduled physical exam

33
Q

How often should pediatric BP be measured in Pre-HTN patients?

A

Recheck in 6 months

34
Q

How often should pediatric BP be measured in Stage 1 HTN?

A

Recheck in 1-2 weeks or sooner if the patient is symptomatic; if BP is persistently elevated on two additional occasions, evaluate or refer to source of care w/in 1 month

35
Q

How often should pediatric BP be measured in Stage 2 HTN?

A

Evaluate or refer to source of care within 1 week or immediately if the patient is symptomatic

36
Q

What is the primary treatment for obesity-related HTN?

A

Weight reduction

37
Q

How should sodium restriction be done for children?

A

< 1500mg/day for 1-3 yo. < 2300mg/day for 14-18 yo

38
Q

What is drug therapy like for pediatric pre-hypertension?

A

Do not initiate therapy unless there are compelling indications such as CKD, DM, HF, LVH

39
Q

What is drug therapy like for pediatric Stage 1 HTN?

A

Initiate therapy based on indications for antihypertensive drug therapy or if there are compelling indications

40
Q

What is drug therapy like for pediatric Stage 2 HTN?

A

Initiate therapy

41
Q

What are the indications for antihypertensive drug therapy in children?

A

Symptomatic HTN. Secondary HTN. Stage 2 HTN. Hypertensive Target-Organ Damage. Diabetes (1 or 2). CKD. Persistent HTN despite non-pharmacologic measures

42
Q

What are some of the main reasons for pediatricians not initiating drug therapy for HTN?

A

Unfamiliar with anti-HTN medications (58%!!!). Concern regarding potential side effects. Adolescent noncompliance. Preference for subspecialty referral. Uncertainty of long-term risks of HTN in pediatric patients

43
Q

What should pharmacologic therapy, when indicated, be like?

A

Should be initiated with a single drug; acceptable drug classes for use in children include ACE-I, ARBs, B-blockers, CCBs, and diuretics. Severe, symptomatic HTN should be treated with intravenous antihypertensive drugs

44
Q

What is the goal for antihypertensive treatment in children?

A

Reduction of BP to < 95th percentile unless concurrent conditions are present, in which case BP should be lowered to < 90th percentile

45
Q

What is first-line treatment for Primary HTN?

A

ACE-I, ARBs

46
Q

What else are ACE-I/ARBs first line for?

A

High plasma renin activity, unilateral renovascular HTN, renal parenchymal disease, proteinuria, CHF, DM, gout, hyperlipidemia, reactive airway disease

47
Q

What are CCBs first line for?

A

Emergency HTN (Nifedipine), DM, COLD, broncopulmonary dysplasia, gout, hyperlipidemia, peripheral vascular disease, renal transplant

48
Q

Why are Diuretics usually not used first line for children?

A

High risk of becoming dehydrated

49
Q

What are the main ACE-Is used?

A

Enalapril. Lisinopril. Fosinopril. Benazepril

50
Q

What is the racial difference with Fosinopril?

A

AA children required higher doses than whites to reach target BP

51
Q

What are the main ARBs used?

A

Losartan. Candesartan. Valsartan. Irbesartan

52
Q

When is Irbesartan ineffective?

A

In patients 6-16 yo

53
Q

What is a secondary effect of Candesartan seen in children 1-6 yo?

A

Anti-albuminuric effect (low dose decreases albumin 20%, medium dose 61%, high dose 69%)

54
Q

How does the Candesartan response differ in age groups?

A

Age 1-2 yo had a much lower response than age 2-6

55
Q

How does the Candesartan response differ with BMI?

A

Patients w/ a BMI > 95 percentile had a much greater response than those < 95%

56
Q

How does the Candesartan response differ in Primary and Secondary HTN?

A

Better response seen in Primary HTN

57
Q

What are the main CCBs used?

A

Nifedipine. Amlodipine (good long acting drug). Felodipine

58
Q

What are the B-Blockers used?

A

Bisoprolol/HCTZ. Metoprolol-ER. Labetalol. Clonidine

59
Q

What was the problem with Bisoprolol/HCTZ?

A

High placebo effect and dropout rate

60
Q

What are the steps taken for the treatment approach to Anti-HTN Rx in children?

A

1) Begin with the recommended initial dose of desired medication. If BP not controlled: 2) Increase dose until desired BP target is reached, or maximum dose is reached. If BP is not controlled: 3) Add a second medication with a complementary MOA. If BP is not controlled: 4) Add a third antihypertensive drug of a different class OR consult a physician experienced in treating childhood and adolescent HTN

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