Arterial Hypertension in children Flashcards
Definition
> 140/90 mmHg
SBP and / or DBP> 95th percentile for
age, sex and height at measurements on 3
different occasions.
Prehypertension
- SBP or DBP between percentiles 90-95.
- Adolescents with BP 120/80 mm Hg will be considered prehypertension.
Indications for ABP measurements
< 3 years – in special cases:
◼ Affections from neonatal period,
◼ Congenital cardiac malformations,
◼ Renal affections or family history of familial renal disease,
◼ Intracranial hypertension,
◼ transplant,
◼ malignancy,
◼ Treatment with drugs that increase the BP,
◼ Other systemic diseases asociated with AHT (neurofibromatosis, tuberose sclerosis, etc).
Recommendations of BP
measurement in children
PREVIOUSLY: -RELAXATION, recreation min 5’.
NOT: food, drink exciting min 30 min prior
POSITION: seated with the arm supported at heart level, REST min 5’
WIDTH cuff
- 40% of the arm length and
80-100% of the circumference
Stethoscope: a brachial K1 and K5 (appearance and disappearance)
BOTH ARMS
3 measurements x 3.
Attention tachycardia.
Anamnesis
Family history of Essential AH
History of chronic renal disease, transplant
Other issues considered risk factors:
- low birth weight,
- malnutrition,
- smoking in adolescents,
- excessive consumption of energy drinks, - sleep apnea syndrome
Medication: sympathomimetic, oral contraceptives, steroids
Cocaine
Symptomatology
nonspecific
headache, vertigo, dizziness,
epistaxis, faintness, visual
disturbances, tinnitus, etc.
DGN
PREHYPERTENSION
AH STD I
AH STD II
PREHYPERTENSION - > Measure BP in 6 months
AH STD I - > X 2, in 1-2 weeks
Investigation
AH STD II -> Confirmation in 1 week
Investigation
Most common cause of HTN in neonates
1) Thrombosis/stenosis of the renal artery, 2) kidney malformations,
3) Co Ao,
4) bronchopulmonary dysplasia
Most common causes of HTN in Infant-6ys
1) renal parenchymal disease,
2) coarctation of the aorta,
3) renal artery stenosis
Most common causes of HTN in 6-10 ys
1) renal parenchymal disease,
2) renal artery stenosis,
3) essential HT
Most common causes of HTN in Adolescent
1) renal parenchymal disease,
2) essential HT,
3) obesity
Renal AHT
3 - 30% AHT in adult,
and between 1⁄2 - 2/3 in
children, being the most frequent
secondary AHT.
There are 2 forms:
◼ renoparenchimal AHT
◼ renovascular AHT
Renoparenchimal AHT
◼ In acute and chronic nephropathy
◼ There is a
- good corelation between volemy and ABP,
the diminished or absence of the plasmatic renin and high total peripheral resistence.
The most frequent renoparenchimal AHT are due to:
Acute or chronic glomerulonephrites
Chronic atrophic pielonephrites,
Renal polycystic disease
Hydronephrosis
Wilms and juxtaglomerular cell tumors
(hemangiopericitom)
Collagen diseases and others
Renovascular AHT
1-2 % in all AHT in adult.
↑in children
Low renal irigation due to the
- stenosis,
- trombosis,
- oclusion or compresive tumor at the renal artery,
- ↑ plasmatic renin,
- hipovolemy and high neurogen activity.
Renovascular AHT in children:
◼ Fibromuscular dysplasia, predominant in female, at the 1/3 median or distal.
◼ In Recklinghausen neurofibromatosis with AH – stenosis due to focal proliferation, predominant intimal, at the renal and intrarenal artery.
Endocrine AHT
Feocromocitoma
Primary hyperaldosteronism (Conn
disease)
Suprarenalian enzymatic deficits
Hipercorticism
Hiper and hipothyroidism
Hiperparathyroidism
Primary reninism
Pheochromocytoma
Neuroectodermal tumor
With paroxistic high release of
cathecolamines
In children – more frequent permanent
AHT and not intermittent
Variable clinical manifestations of feochromocitoma
◼ norepinefrins,
most frequent- α adrenergic manifestations (SHT,DHT, tahicardia),
◼ epinefrins
- β adrenergic manifestations (SHT, tahicardia, hipermetabolism, hiperglicemia, anxiety, sometimes hypotension)
◼ dopamin, very rare, with normal or even low ABP, tahicardia, diarhea, poliuria and nausea.
Aortic coarctation
= variable stenosis
of the aortic arch with the eccentric
lumen.
Types of Aortic coarctation
◼ Postductal or adult type, the most
frequent, with tight stenosis under the
arterial channel origin
◼ Preductal or infantil type, between the
subclavicular artery and arterial channel.
This type is frequent associated with
severe cardiovascular anomalies.
Investigations
Basic tests:
◼ blood count,
◼ urea and serum
◼ creatinine,
◼ Urine,
◼ ENT examination,
◼ Chest X rays,
◼ ECG
◼ Ophtalmology examination
◼ Metab carbohydrate, lipid,
◼ ionogram serum, and urine possibly
◼ urine culture
Investigations
Specific tests
◼ cardiac ultrasound,
◼ abdominal and renal Doppler aa ultrasound,
◼ arteriography,
◼ Hormonal Dosage:
- thyroid,
plasma renin,
plasma aldosterone,
urinary ionogram,
cortisol levels,
urinary free cortisol,
dexamethasone suppression test,
serum or urinary catecholamine dosage (Vanil mandelic acid),
◼ Computed Tomography
Indications for treatment
ST I
Symptomatic hypertension
Secondary hypertension
Hypertension with target organ damage
Association of type 1 or 2 diabetes
AH despite persistent non-
pharmacological measures
Antihypertensive medication
Initiation - an antihypertensive at
minimum recommended dose,
preferably angiotensin converting
enzyme inhibitor (ACEI)
ACEI (captopril, enalapril) - obesity
associated with AH
Calcium channel blockers
Thiazides diuretics
Antihypertensive medication
“step-up” therapy
Associations
After achieving BP control -
measuring 6 months is a
candidate for “step down”
Specific treatment
Pharmacological treatment (1)
One drug at minimum dose
β adrenergic non-/selective antagonist
◼ propranolol (1-4 mg/kg/day)
◼ metoprolol (1-6 mg/kg/day)
IECA - ACEi
◼ captopril,0,3-6 mg/kg/day,
◼ enalapril-0,1-0,5 mg/kg/day,
Calcium channels blockers
◼ nifedipin SR 0,25-3 mg/kg/day
Pharmacological treatment (2)
Then the “step up” therapy
In 2 weeks the BP – not controlled
◼ The second antihypertensive drug
If the second drug is not enough
◼ The third even the fourth drug
Diuretics can be associated:
- clorotiazid (20-30 mg/kg/day),
- hidroclorotiazid, 1-3 mg/kg/day,
- spironolactone (1-3 mg/kg/day),
- furosemide (0,5-6 mg/kg/dose).
Other classes of antihypertensive drugs can be used now in children:
- blocker of the angiotensin II receptors,
- losartan (0,7-1,4 mg/kg/day),
- irbesartan
After stabilization ABP must be measured at 6 months and the „step down” can be tried.
Treatment of the emergency
hypertension
Admitted
DABP ≥120 mmHg.
ABP must be reduced with 20-25% in first 8 hours, then ↓ gradualy, in weeks.
Can be used the 2 ways
◼ parenteral or
◼ oral – calcium channel blockers, nifedipin, 0,2-0,5 mg/kg/dose (10 mg/dose)
Parenteral:
◼ labetalol, in bolus 0,2-1 mg/kg/dose in 2 minutes or in pev, 0,4-3 mg/kg/h
◼ Associated, if necessary, with sodiu nitroprusate, 0,3-10 μg/kg/min in pev
◼ Others.
